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7./ : 



^- > I 



I 



THE TREATMENT 



OF 



FRACTURES 



BY 

CHARLES LOCKE SCUDDER, M.D. 

ASSISTANT IN CLINICAL AND OfKRATIVE SUKGF.K^ HAKVAKD I'MVF.KSITY MEDICAL SCHOOL 



ASSISTED BY 

FREDERIC J. COTTON, M.D. 



SECOND EDITION, REVISED 



mitb 0tt 1llu0tration0 




PHILADELPHIA AND LONDON 

W. B. SAUNDERS & COMPANY 

I901 



•• •• :* 



• • • 



• • 



• • •• • 

• • • 

• • ••• 

• •• • 



• • 









• • • 

• • • • 



Copyright, kjoi, by W. B. Saunders &. Company 



Registered at Stationers' Hall, London, England 



v^\o \ 



TO 
ARTHUR TRACY CABOT, A.M., M.D. 



PREFACE TO THE SECOND EDITION 



In this edition many X-ray plates have been reproduced to 
assist in famiHarizing the reader with the interpretation of such 
plates. Physicians should be able to interpret X-ray plates 
without the assistance of an expert. 

A series of clinical cases has been introduced to render more 
helpful the chapter upon Skull Fractures. Numerous illustra- 
tions have been added to the chapter upon Plaster-of- Paris. 
Emphasis is laid upon the use of plaster-of-Paris in the treat- 
ment of almost every fracture. The Index has been made more 
serviceable. 

Through the kindness and liberality of the publishers the 

addition of new illustrations has enhanced the practical value 

of the book. 

Charles L. Scudder 

189 Beacon Street, Boston, Mass. 
January ^ tgoi 



PREFACE TO THE FIRST EDITION 



The general employment of anesthesia in the examination 
and the initial treatment of fractures, especially of those near or 
involving joints, has made diagnosis more accurate and treat- 
ment more intelligent. The application of the Rontgen ray to 
the diagnosis of fracture of bone has already contributed much 
toward an accurate interpretation of the physical signs of frac- 
ture. This greater certainty in diagnosis has suggested more 
direct and simpler methods of treatment. Antisepsis has opened 
to operative surgery a very profitable field in the treatment of 
fractures. The final results after the open incision of closed 
fractures emphasize the fact that anesthesia, antisepsis, and the 
Rontgen ray are making the knowledge of fractures more exact, 
and their treatment less complicated. The attention of the stu- 
dent is diverted from theories and apparatus to the actual condi- 
tions that exist in the fractured bone, and he is encouraged to 
determine for himself how to meet the conditions found in each 
individual case of fracture. 

This book is intended to serve as a guide to the practitioner 
and student in the treatment of fractures of bone. In the follow- 
ing pages many of the details in the treatment of fractures are 
described. So far as possible these details are illustrated. A 
few very unusual fractures are omitted. Mechanical simplicity 
is advocated. Splints of special manufacture are not described, 
as their use distracts attention from the fracture. An exact 
knowledge of anatomy combined with accurate observation is 
recognized as the proper basis for the diagnosis and treatment 
of fractures. The expressions ** closed " and '* open " fracture 

are used in place of ** simple*' and ** compound " fracture. 

II 



1 2 PREFACE 

'* Closed " and ** open '* express definite conditions, referring to 
the freedom from, or liability to, bacterial infection. The old 
expressions are misleading despite their long usage. Theories 
of treatment are not discussed. Types of dressings for special 
fractures are described. Many illustrative clinical cases are 
omitted purposely. 

The tracings of the Rontgen rays, which have been very 
generally used to illustrate the sites and the displacements ol 
fractures, have been the subject of careful study. Each tracing 
represents the combined interpretation of the plate made by 
skilled observers who were in every instance familiar with the 
clinical aspects of the case. The writings of many who have 
contributed their experience to the literature of fractures have 
been consulted. Those to whom I feel indebted for suggestions 
are mentioned in the section on Bibliography. References to 
literature are not made in the text. 

I take this opportunity to extend my thanks to the members 
of the Surgical Staff of the Massachusetts General Hospital for 
their courtesy in permitting me to study cases of fracture of the 
lower extremity in the wards of the hospital, and to Professor 
Thomas D wight for the use of valuable anatomical material. I 
also thank Dr. F. J. Cotton for an untiring interest in the pro- 
duction of most of the drawings, and in the search for fracture 
literature. The half-tones are made from photographs taken 
under the direct superintendence of the author. Due credit for 
illustrations not original is given next the legend. 

I wish to thank Mr. Walter Dodd for his courtesy and inter- 
est connected with the production of the Rontgen-ray plates, 
and Dr. H. P. Mosher for kind assistance. 

The chapter on the Rontgen ray is written by Dr. E. A. 

Codman. 

Charles L. Scudder 

189 Beacon Street, Boston, Mass. 
Aprils igoo 



TABLE OF CONTENTS 



CHAPTER I PAGF 

Fractures of the Skuli 17 

Fractures of the Vault 22 

Fractures of the Base 24 

Treatment 34 

Pistol Shot Wounds of the Skuli 37 

I^ter Results of Fracture of the Skull 38 

CHAPTER II 

Fractures of the Nasal Bones 44 

The Nasal Septum 47 

Treatment 49 

Fractures of the Malar Uone 52 

Treatment . . 54 

Fractures of the Superior Maxilla 55 

Treatment 56 

Fracturf-s of the Inferior Maxilla 58 

Treatment 61 

CHAPTER III 

Fractures of the VERTEBR^t 72 

Treatment 81 

CHAPTER IV 

Fractures of the Ribs 91 

CHAITER V 

Fractures of the Sternum 96 

CHAITER VI 

Fractures of the Pelvis 99 

Treatment loi 

Rupture of the Urethra 103 

Rupture of the Urinary Bladder 104 

13 



,^ TABLE OF CONTENTS 

CHAPTER VII 

PAGE 

Fractures ok the Clavicle jq5 

Treatment in Adults 109 

Treatment in Children .... u^ 

Operative Treatment 116 

CHAPTER VIII 

Fractures of the Scapula ,,g 

Treatment 119 

CHAPTER IX 

Fracturf:s ok the Humerus 121 

Fractures of the Uf*per End of the Htwierus 1 21 

Diagnosis .... 126 

Treatment 137 

Fracture of the Upper Ettd of the Humerus with a Dislocation of the Cpper 

Fragment 142 

Fractures of the Shaft of the Humerus 1 44 

Fractures of the Shaft with Little Displacement 146 

Fractures of the Shaft with Considerable Displacement 151 

Fractures of the Shaft in the New-bom 153 

The Mu.scuIosp«ral Nerve in Fracture of the Humerus 153 

Malignant Disease Associated with Fracture of Bone 155 

Fractures of the Elbow 155 

Diagnosis 164 

Treatment 176 

CHAPTER X 

Fractures of the Bones of the Forearm 187 

Fractures of Both Radius and Ulna 187 

Treatment 194 

Nonunion of Fractures 207 

Fractures of the Olecranon 210 

Treatment 213 

Tetanus 219 

Colles^ Fracture 219 

Diagnosis 227 

Treatment 232 



CHAPTER XI 

Fractures of the Carits, Metacarpus, and Phalanoks 242 

Fractures of the Carpus 242 

Fractures of the Metacarpus 245 

Fractutes of the Phalanges 251 

Open Fractures of the Phalanges 254 



TABLE OF CONTENTS I 5 

CHAPTER XII ,.AGE 

Fractures of the Femur , 256 

Fracture of the Hip or Neck of the Femur 256 

Treatment 265 

Operative Treatment 274 

Fracture of the Neck of the Femur in Childhood 274 

Fracture of the Shaft of the Femur 278 

Treatment 279 

Subtrochanteric Fracture of the Femur 295 

Supracondyloid Fracture of the Femur 296 

Ambulatory Treatment of Fracture of the Thigh 299 

Fracture of the Thigh in Childhood 305 

Separation of the Lorver Epiphysis of the Femur 309 

Treatment 314 

Traumatic Gangrene 317 

Septicemia 317 

Malignant Edema 317 

Fat Embolism 318 

CHAPTER XIII 

Fractures of the Patella 319 

Treatment 324 

Open Fracture of the Patella 333 

Operation in Recent Closed Fractures of the Patella 337 

CHAPTER XIV 

Fractures of the Leg 341 

Treatmtrnt 35 1 

Fractures with Little or No Displacement 351 

Fractures with Considerable Immediate Swelling 354 

Fractures Difficult to Hold Reduced 365 

Treatment of Open Fractures of the Leg 369 

1 hrombosis and Embolism 378 

Pott's Fracture 379 

Treatment 382 

Open Pott's Fracture 394 

CHAPTER XV 

Fractures of the Bones of the Foot 396 

Fracture of the Astragalus 396 

Open Fracture of the Astragalus and Os Calcis 401 

Fracture of the Metatarsal Bones 401 

Fracture of the Phalanges 402 

CHAPTER XVI 

Anatomical Facts Regarding the Epiphyses 403 



I 6 TABLE OF CONTENTS 

CHAPTER XVII PACK 

The R5NTGEN Ray and Its Relation to Fractures 409 

By Dr. E. A. Codman 

CHAPTER XVIII 
The Employment ok Plastkr-of- Paris 425 

CHAPTER XIX 
The Amkulatory Treatment of Fractures 440 

BIBLIOGRAPHY 449 

INDEX 453 



THE TREATMENT OF FRACTURES 



CHAPTER I 
FRACTURES OF THE SKULL 

The skull is the brain's protection. In cases of fracture of the 
skull the injury to the brain is of paramount importance. The 
immediate damage to the brain may be caused by direct pressure 
of bony fragments, by pressure due to hemorrhage from torn 
vessels within the skull, by bruising of the brain itself, or by 
cerebral edema. Great interest attaches to serious head- 
injuries, not only because the brain may be damaged, but more 
especially because the lesions are often obscured by an intact 
scalp. A proper determination of the conditions existing after a 
given head-accident necessitates careful observation of symptoms, 
combined with good judgment in interpreting the signs present. 

Concussion and Contusion of the Brain. — A concussion and 
a contusion of the brain associated with minute bruising of brain- 
tissue will exist after all injuries of importance to the skull. 

The symptoms of concussion are varied according to the 
severity of the injury. Following slight concussion, the individ- 
ual is stunned by the accident ; there is simple vertigo, possibly 
mental confusion lasting but a short time. After severe concus- 
sion there will follow a momentary loss of consciousness, or there 
may be unconsciousness of longer duration. Vomiting may 
occur. Headache will probably be present. Following a still 
more severe concussion, the patient will be profoundly uncon- 
scious for a long period. The sphincters will be relaxed ; hence 
involuntary micturition and defecation. The pulse will become 

feeble and slow along with the general systemic depression. The 
2 17 



1 8 FRACTURES OF THE SKULL 

pupils still react to light. The temperature will be subnormal. 
It is impossible clinically to distinguish between concussion and 
contusion of the brain. The pathological differences are more 
or less artificial. 

Laceration of the Brain. — If there is laceration of the brain, 
the symptoms of concussion will be present to a marked degree, 
and will be characterized by immediate, pronounced, and long- 
continued unconsciousness. After recovery from the initial 
shock of the accident fever will be present, which may rise to 
103° or 104^ F. Concussion is never associated with feverish- 
ness. Early fever is a sign of laceration. Mental irritability 
and restlessness will mark returning consciousness. If the motor 
areas of the brain are involved, then signs of irritation will ap- 
pear — namely, muscular twitchings and spasms according to the 
motor centers implicated. 

Compression of the Brain. — Slight hemorrhages do not cause 
symptoms of compression ; neither do slight depressions of the 
cranial bones. Before symptoms of compression appear, the 
cranial cavity must be impinged upon to a very considerable ex- 
tent. If the compression is sudden and limited, there is an irri- 
tation of the parts involved, which is manifested by restlessness 
and deUrium and by twitching of certain groups of muscles ; the 
pulse is hard and slow. If the -compression is gradual, whether 
it be localized or diffused, the brain accommodates itself for some 
time to the new conditions ; the appearance of the symptoms of 
local pressure is delayed, although they may be relatively sudden 
in their onset. Following the muscular spasms and twitchings 
due to the sudden onset of pressure there may appear symptoms 
of paresis and paralysis. Loss of power in the face or arm or leg 
indicates the seat of the lesion to be about the fissure of Rolando, 
upon the side of the brain opposite to the affected side. Dilatation 
of the pupil of one side will be noticed if there is pressure upon 
the third nerve at the base of the skull. This pupil will not react 
to light. As the pressure of the hemorrhage increases, the symp- 
toms will again become more general ; convulsive movements of 
the limbs and body appear, and the drowsiness or stupor increases 
to profound unconsciousness ; the pulse becomes rapid and 
small ; and the respiration frequent, shallow, and sighing, or it 



EXTRADURAL HEMORRHAGE I9 

passes into stertor and Chcyiie-Stokes" breathing as the condition 
becomes immediately grave ; the temperature rises high. Focal 
symptoms may exist from pressure by bone or blood-clot, apart 
from loss of consciousness. 

Extradural Hemorrhage (see Figs, i , 2). — The most impor- 
tant symptom of intracranial hemorrhage is the interval of con- 
sciousness that exists from the time of the injury to the onset of 
unconsciousness. Unconsciousness incases of intracranial hem- 
orrhage is due to an increase of the intracranial pressure caused 
by the presence of free blood. An interval of consciousness 





Fig. t.-Fncliirc of ikull with n<l<ldlc 



KiK. j.-FraciuK of »kull wliI. d. 



exists in these instances in from one-half to two-third,s of all 
cases. In the cases of hemorrhage which occur without an in- 
terval of consciousness (unconsciousness coming on immediately 
upon the receipt of the injury) it must be that the injury is so 
severe that the unconsciousness caused by the concussion and 
laceration of the brain is continuous with the unconsciousness 
from hemorrhage. The unconsciousness of concussion is con- 
tinued over into the coma of compression. The duration of the 
interval of consciousness may vary within very wide limits : it 
may be a few moments, it may be three months. 



20 FKACTOKES Oi'^ TEiE SKULL 

The sources of intracr.ini;il hemorrhage, whether from the 
middle meningeal artery (see Fig. 3) or its branches (see Fig. 4), 
from the middle cerebral arteries, from the veins of the pia mater, 
from the inner surface of the dura, from the sinuses of the brain, 
or from lacerated brain-tissue, can not be easily differentiated 
short of operative procedure. There is one condition which is 
not to be overlooked tn connection with the question of hemor- 
rhage — namely, the period of semiconsciousness which some- 
times follows concussion and laceration, and gives rise to the 
suspicion of some more serious gross lesion. To illustrate : A 
young girl received a severe blow upon the head. A true 




period of unconsciousness followed. There were no external 
evidences of hemorrhage. Convulsive movements, deviation of 
the eyes, and disturbance of the pupils were absent. The 
breathing was regular and of normal character. Notwithstand- 
ing the absence of other untoward symptoms, complete con- 
sciousness did not return for a number of days or even of weeks. 
In such a case, after a number of days the question naturally 
presents itself, Have we not to do with a hemorrhage, and 
should not trephining be considered ? The absence of all symp- 
toms excepting ihc unconsciousness should lead to the suspicion 
that wc have to do with a mental slate rather than with a gross 



THE FRACTURE OF THE SKULL 



21 



lesion. Hysteroid semiconsciousness (Walton) supervening upon 
a blow is not to be mistaken for the deepening unconsciousness 
which indicates hemorrhage. 
Subarachnoid Serous Exudation (Cerebral Edema). — A 

severe blow upon the head, with or without fracture of the skull, 
may result in a local bruising and in congestion and swelling of 
the brain-tissue, with serous exudation into the subarachnoid 
space, either with or without edema of the brain-substance. If 
this accumulation of fluid occurs over the motor area, localized 
symptoms, as if of hemorrhage, may appear. The lesion is usu- 
ally self-limited, the resulting paralysis disappearing in the course 
of a few days. The careful observation of the onset and sequence 
of the signs of compression is of the very greatest importance. 





Fig. 5. — Splinteriiifi: of inner table; cross-sections; diagrammatic: a. Usual form of 
punctate fracture ; b shows that a linear fracture may be much more extensive internally 
than externally. 

for it IS by a proper interpretation of these localizing symptoms 
that the surgeon is led to operate, and then is enabled to remove 
the compressing blood-clot or the depressed fragment of bone. 



THE FRACTURE OF THE SKULL 

Whether the wound of the bone is compound or simple, open 
or closed, is of comparatively little importance, because of the 
very general recognition and employment of aseptic and antisep- 
tic methods. A knowledge of the nature of the fracture will 
help in determining the injury to the brain. If there is a per- 
forating fracture, or if the fragments are comminuted or depressed, 
then it is highly probable that a tremendous or sharply localized 
force has been exerted upon the bone, and that, in consequence, 
the injury to the underlying brain is serious. It is a generally 



accepted fact that the skull may be simply contused and the great 
lateral sinus ruptured, with resulting fatal hemorrhage. It is 
likewise true that the bone may present but a fissure, but if that 
fissure crosses the middle meningeal arterj', or any of its branches, 
they may be toni across, and the consequent hemorrhage and 
associated intracranial pressure will prove disastrous unless 
checked by surgical interference. On the other hand, the bone 
in the frontal region may be greatly damaged, litfrally crushed. 




and yet no grave symptoms arise (see Fig. 6). The extent of 
the bone-lesion is, however, of the greatest importance. 

Fractures of the Vault of the Skull (see Fig. 8).— Frac- 
tures of the vault of the skull without involvement of llie base 
are much more unusual than is generally supposed. More than 
two-thirds of all fractures of the vault are associated with frac- 
ture of the base of the skull (see Figs. 8, 9, 10, 1 1 ). Evidences 
of fracture of the vault are determined by sight and touch. A 
wound in the scalp may disclose the fractured bone. Whether 



24 



FRACTURES OF THE SKULL 



this is a mere fissure or a single or a comminuted fracture, 
whether depressed or not below tlie general surface of the 
normal skull, can be determined only by careful inspection. 
A fissure of the bone may be difficult of recognition. It must 
be remembered in this connection that blood can not be wiped 
from a fissure, whereas from the normal suture lines it can readily 
be wiped away. Hlood may be seen escaping through a fissure. 
Torn periosteum must not be confused with a fissure of the bone. 
A hematoma of the .scalp may suggest a depressed fracture of 
the skull (sec Fig. 12). The center of the blood-tumor is soft ; 




the edges are edematous and hard. If the finger be pressed 
firmly into the .soft center, an intact skull generally will be felt. 
The uniform edge of a hematoma is unlike the irregular bony 
edge of a fracture. 

Fracture of the Base of the Skull (see Figs, 13, 14, 15). — 
It is not uncommon to discover that what in the vault appears to 
be a simple fissure continues down to and involves the base of 
the .skull. Fractures of the base of the skull are usually rc- 
^'urdcd, and rightly so, as more serious than fractures of the 
vault. A [greater trauma bcinj; necessary to cause the fracture. 
the cerebral disturbance is more pronounced and vital part'^ 



FRACTtTRES 0€ THE rKLXl. 



are endangered. These iractures of t&e base often open 
into cavities nrtiicli it ts impo^sibic; to fce«D surgicailv ciean — 
nameiy, the canities or the naso- 
phar^TX and the ear. The 
danger of sepdc iniection. there- 
fore. En such frat-ture* is VKxy 
great About eig&t>--ffv'e per 
cent, of basK fractures originate 
in the ii^utc — i. ^.. are caused bj- 
an cxtenstDD of a [ioear fracture 
of the ^-ault to the base. A few 
boiic braccures are due to forces 
acting iTom bctow and thus caus- 
ing a penetration of the bare of the ^kul! by other bones. The 
iidn.1 b"3nes may be torcec up into the anterior Wssa i iee Fig. 16). 




iB^us ' Alter Heif^cb 




SYMPTOMS OF FRACTUKE OF THE iiASE 2/ 

into the middle fossa by a blow upon the chin, particularly if the 
jaw is relaxed. The vertebral column may be forced up into the 
posterior fossa through a fracture of the occiput. 

Symptoms of Fracture of the Base. — Hemorrhage from the 
ear, from the nose, or from the mouth may be present; also 
subconjunctival hemorrhage. Hemorrhage beneath the pharyn- 
geal mucous membrane may occur. Escape of cerebrospinal 
fluid from the ear and nose occurs, and escape of brain-tissue 
from the skull. Injuries to various nerves occur. Associated 
with these local signs may be the general signs of concussion or 
laceration of the brain. 

If the orbital plate of the frontal bone is broken, blood will 




gravitate into the orbit ; ecchymosis of the lids and subconjunc- 
tival hemorrhage will appear. There may be greater tension 
of that eyeball upon the affected side, detected by palpating the 
globe through the closed lid. Subconjunctival hemorrhage 
may appear from a fracture of the malar or superior maxillary 
bones. 

If the cribriform plate of the ethmoid is fractured, hemorrhage 
from the nose will occur (sec Fig. 1 8). Impairment of the sense 
of smell mayexi.st if the olfactory nerves become involved in the 
fracture. Blood may trickle from a fracture of the base into the 
pharynx, be swallowed, and later vomited. Mpista.vis, of course, 
may be due to a blow upon the face without fracture of the base. 



28 KKACTLKES OV THE SKULL 

If inspection discloses a broken nose or ccchymosis of the face or 
the skin of the forehead, it is very probable that the minor acci- 
dent has occurred. Most fractures of the base involve the middle 
fossa. 

If the petrous portion of the temporal bone is fractured, several 
important signs appear (see Fig. 19). If the tympanum is torn, 
hemorrhage from the external auditory meatus is ■)ure to follow. 
If this hemorrhage is continuous it is significant if it is trifling 
and temporary, it is probabl> unimportant Cerebral tissue 
may escape from the nose, thus estabhshnig the seat of the 
lesion. Cerebrospinal fluid may likewise escape from the 
ear. Cerebral tissue may also appear at the external audi- 




tory meatus. Any of these signs is conclusive evidence 
that the base of the skull is fractured and that there is a 
lesion of the brain. Lesions of the facial (seventh) and 
auditory (eighth) nerves lying within the bones occur. Lesions 
are likewise reported of the fifth nerve, because of its lying 
upon the petrous portion of the temporal bone. Subconjunc- 
tival hemorrhage may appear, owing to the blood working its 
way forward and through the sphenoidal fissure and the optic 
foramen. A primary profuse watery discharge from the nose 
or the ear is probably cerebrospinal fluid. A watery discharge 
appearing late after such an injury is likely to be serum from 
a blood-clol. The optic nerve may be involved, and complete 
loss of vision result. 



CERTAIN CAUSES OF UNCOKSCIOUSftESS 




If tlic posterior fossa (sec Fig. 20) is involved in the frac- 
ture, there may be hemorrhage into the pharynx. Ecchymosis 
under the pharyngetil mucous membrane may be present without 
actual rupture of the mucous mem- 
brane. A fullness may be detected 
by palp.ttion in the posterior wall 
of the pharynx, if the hemorrhage 
there is considerable. Ecchymosis 
Justin front of the mastoid process, 
or a hematoma and puffy swelling 
over the seat of the fracture, may 
determine its location. 

Certain Causes of Unconscious- 
ness. — There are certain conditions 
associated with loss of conscious- 
ness and delirium which must be 
differentiated from intracranial le- 
sions. These conditions are (a) the 
coma from opium-poisonmg; (o) of n.c sk..ii. 

the unconsciousness in uremia ; 

((■) the loss of consciousness from apoplexy ; ((/) alcoholic coma ; 
and (c) hemorrh^ic internal pachymeningitis. 

Coma from Opium-poisoning: The [ratient can be aroused 
unless the poisoning is extremely profound, and can be made to 
understand, and will even reply to an inquiry. The face at first 
is pale, later it is flushed and swollen. The skin is warm and 
moist. The respiration isslow. The temperature issubnormal. 
The pulse is slow and full. The pupils arc strongly, immovably, 
and symmetrically contracted. The reflexes may be absent. 

The Unconsciousness in Uremia : The patient can not be 
aroused. The face is white, edematous, and pufly. The breath 
has a sweetish odor. The respiration is frequent and irregular. 
The temperature is normal. The pulse is rapid. The pupils 
.nre dilated and sluggish. The urine contains albumin. 

The Unconsciousness from Apople.xy : The patient can not be 
aroused. The respiration is slow, irregular, and stertorous. 
The temperature is subnormal at first; if a fata! termination is 
probable, the temperature is high. The pupils arc dilated. Uni- 



30 FRACTURES OF THE SKULL 

lateral paralysis of the face and the extremities usually is present. 
The affected extremities are warmer than those of the other side. 
The limbs may be relaxed, but in watching the patient carefully 
evidences of hemiplegia will appear. 

Alcoholic Coma : The patient can be aroused by pressure upon 
the supra-orbital nerves — sometimes, however, with great diffi- 
culty. The breath may be alcoholic. The face is flushed. The 
respiration is regular. The pulse is rapid. The temperature is 
normal or low. The pupils are normal. There is an absence of 
the positive signs of a cerebral lesion. The temperature in cere- 
bral laceration is elevated. Alcoholic delirium will present an 
elevated temperature, but along with the elevated temperature 
of a lacerated brain there will be symptoms characteristic of a 
damaged brain. 

Hemorrhagic Internal Pachymeningitis : The occurrence of 
apoplectic seizures during the course of this disease makes it im- 
portant that it be recognized in connection with the distinctly 
traumatic hemorrhages under consideration. The characteristic 
course shows an acute diffused affection of the brain, usually in 
an elderly man and with severe symptoms. An acute attack 
is followed by a fair recovery and by intervals of comparative 
health. During these intervals of comparative health the patient 
has some headache, slight diminution of intelligence, impairment 
of memory, drowsiness, partial paralysis of the limbs (usually 
unilateral), disturbances of speech, and sudden mental excitement 
without cause mixed with symptoms of paralytic dementia. Evi- 
dences of a sudden and increasing compression are headache, 
drowsiness, loss of consciousness, some fever, a pulse of com- 
pression, and sometimes initial symptoms of irritation. The diag- 
nosis is assisted by the etiology and history of the case. In 
middle meningeal hemorrhage a blow is necessary to cause 
alarming symptoms, whereas in hemorrhagic pachymeningitis 
a very trivial injury or none at all is common. The longer 
duration of the symptoms would help to decide against middle 
meningeal hemorrhage. There is often a rigidity of the limbs in 
hemorrhagic pachymeningitis which is absent in middle menin- 
geal hemorrhage cases. 

When called upon to see a case of head-injury, it must be 



EXAMINATION OF THE PATIENT 3 I 

remembered that the lesion can not always be determined by tlic 
first observation of the patient. It is absolutely necessary that 
there be, upon the part of the physician, a clear understanding 
of the method of onset and the sequence of symptoms from the 
receipt of the injury. Isolated signs are of less importance than 
relative symptoms. 

Examination of the Patient.^-The following comprehensive i^"^'^ 
method of examining an individual who has received a severe 
injury to the head should be carefully followed, bearing in mind 
always the possible cranial and intracranial lesions, and remem- 
bering that a fracture of the skull as such is of secondary impor- 
tance, that an injury to the intracranial vessel is serious, and that 
a lesion of the brain itself is most important. 

If with brain symptoms there is no visible injury to the skull, 
the head should be shaved to facilitate careful examination. 
Acute localized pain suggests the seat of fracture when it is not 
visible. 

When was the accident ? How much time has elapsed be- 
tween the accident and the first accurate observation ? 

What was the accident ? Was it a fall or a blow ? 

What is the age of the patient ? Are the arteries atheroma- 
tous, and therefore easily ruptured by trivial injury? Is it the 
skull of a child — which is softer and less brittle than that of an 
adult ? 

What was the condition of health previous to the accident ? 
Was it poor — suggestive of kidney-disease and uremia ? Was 
the man alcoholic, or is the present condition masked by alcohol 
taken subsequent to the accident ? 

The General Condition of the Patient: If unconsciousness is 
present, was its onset immediate, or was there a lucid interval 
after the accident ? Has the unconsciousness been continuous, 
and is it deepening or lessening ? 

What arc the evidences of shock present ? What is the con- 
dition of the pulse, of the respiration, of the skin ? What is the 
temperature taken in the rectum? Has vomiting occurred? 
Have there been involuntary dejections ? Has there been invol- 
untary micturition ? 

The Local Condition : The wound of the scalp or skull or 



32 FRACTURES OF THE SKULL 

brain may be evident. If hemorrhage is present, what is its 
source ? Is it from the nose, the mouth, the ear, or into the 
orbit ? When did the hemorrhage occur ? What was its amount ? 
Was it continuous or not ? Palpation should be made of the 
skull, the neck, the face, the spine, the jaw, and the temporo- 
maxillary joint. 

Are any localizing signs present ? What is the condition of 
the pupils, and of the muscles of the face, the arms, and the 
legs ? What is the condition of the reflexes and of the respira- 
tion ? Does hemiplegia, cither partial or complete, exist ? 

Finally, the whole body should be examined systematically 
for any other injuries than those to the head and to the nervous 
system. Associated injuries, if discovered, may assist in inter- 
preting the nature of the cerebral injury. 

A diagnosis must be based upon all available evidence. One 
will have to consider concussion and laceration of the brain and 
pressure upon the brain by serum, blood, and bone. The 
important signs to be studied in diagnosis are the different aspects 
of unconsciousness ; the relative and actual conditions of the 
respiration, pulse, and temperature ; the occurrence of hemor- 
rhage ; irritability in temperament and in muscle ; localizing 
signs of pressure. If the symptoms are not positive, if there is 
no history of trauma, if the history of a lucid interval preceding 
unconsciousness is doubtful, or if there is no history at all, then 
the diagnosis will be most difficult. It is when positive symp- 
toms are absent that one must particularly consider those condi- 
tions already mentioned in which coma is a prominent sign — 
namely, opium-poisoning, uremia, apoplexy, alcoholism, and 
pachymeningitis h;emorrha<^ica. 

General Observations. — An unconscious man having a scalp 
wound and a breath smelling of liquor is not, necessarily, 
drunk. He may have an intracranial lesion. Multiple lesions 
may be present in any case. A diffuse lesion may obscure a 
localized lesion. Not onlv must the location of a lesion be 
(ietermincd, hut also its character, if possible. The symptoms 
must be rcrcorded in the order of their appearance. The man- 
ner in which xarious symptoms develop should be noted. The 
danger to the brain is greatest in perforating and sharply 



GENERAL OBSERVATIONS 33 

depressed fractures. Slight fissures may be associated with grave 
hemorrhages. Great comminution of bone may be devoid of 
much danger. In cases of compound fracture fissures appar- 
ently closed afford the possibility of cerebral and meningeal 
infection through dirt having entered when the fissure was open. 

Unconsciousness and a superficial head-lesion, with or without 
fracture of the skull, must make one suspicious of an intra- 
cranial lesion. An immediate loss of consciousness indicates a 
diffused contusion or concussion of the brain. If the primary 
unconsciousness is prolonged, probably hemorrhage has oc- 
curred, or possibly a serous exudation with its resulting pressure 
upon the brain. If there is a conscious interval preceding the 
unconsciousness, a hemorrhage is probable. Momentary uncon- 
sciousness means concussion. Recurring unconscious p>eriods 
indicate hemorrhage. Deepening unconsciousness indicates in- 
creasing intracranial pressure — probably hemorrhage. Imme- 
diate profound unconsciousness suggests hemorrhage from the 
rupture of an intracranial sinus. 

The temperature in all intracranial lesions is usually slightly 
above normal. Intoxication and shock depress the temperature. 
In a small intracranial hemorrhage there will be a slight rise of 
temperature, perhaps to 99° F., following the initial drop a few 
hours after the injury. In cerebral laceration one finds a higher 
initial temperature than in hemorrhage, and in fatal cases the 
temperature remains elevated. If the temperature rises quickly 
and early, an important laceration is present ; if after several 
hours of unconsciousness the temperature remains about 99° or 
99.5° F., there is probably a hemorrhage rather than a severe 
direct lesion ; if, on the other hand, the temperature rises higher, 
there is a cerebral lesion, alone or associated with a hemorrhage. 
If the temperature does not rise very high and advances rather 
slowly, there is a contusion or a concussion with slight lacera- 
tion or a slight hemorrhage. A slow, full pulse with stertorous 
respiration suggests pressure, most often from extradural hemor- 
rhage. Early and very slow respiration is associated with pres- 
sure upon the medulla. 

Paralysis of the limbs and the face is characteristic of serous 
exudation, hemorrhage, or bony pressure. Irregular muscular 
3 



34 FRACTURES OF THE SKULL 

contractions suggest laceration of motor areas. Mental disturb- 
ance may be due to cerebral lesions. That brain-tissue escapes 
from the ear does not necessarily signify that the patient will 
not recover. Fractures of the base of the skull occur without 
marked symptoms and recover without the necessity of operation. 
Treatment. — There are cases of injury to the skull so serious 
that it is evident that operation will be of no avail. There are 
cases of simple concussion in which only careful nursing is de- 
manded. There is a large and increasing number of serious 
head-accidents in which operative interference will prove of great 
value. The collapse from shock may be well-nigh complete, 
but restorative measures are not to be neglected upon this 
account. If hemorrhage is suspected, stimulation of the circu- 
lation must be very guarded. The patient should be placed hori- 
zontally, with the head slightly raised, and kept quiet. The 
whole body should be wrapped in warm blankets. Warm 
water-bottles should be put on the outside of the bed about the 
patient, one at each foot, three along each side of the body. 
The water in these bottles should be comfortably warmed — 
1 00° F. Hot water is never to be used. Patients under these 
circumstances are insensible to heat, and severe burning of the 
skin may occur if very hot water is used in the bottles. 

If there are no indications for immediate operation, and local- 
izing symptoms are absent, the patient is to be treated sympto- 
matically. The pulse is to be carefully watched to detect varia- 
tions in strength, rate, and rhythm. The character and frequency 
of the breathing are to be likewise noted. Gentle stimulation sub- 
cutaneously by sulphate of strychnin (^^ of a grain), administered 
as needed, will often steady a pulse remarkably. A special 
nurse or an intelligent watcher should be with the patient con- 
stantly, to note any localizing signs of pressure, such as twitch- 
ing of the muscles of the face or limbs and variations in the 
pupil, to record movements of the limbs, and to make hourly 
observations of the pulse, temperature, and respiration, and any 
variation in consciousness. These observations will be of in- 
estimable value in determining diagnosis, prognosis, and treatment. 

The various cavities exposing the brain to infection should be 
cleansed. 



TREATMENT OF FRACTURES OF THE SKULL 35 

The Nose. — The nose should be douched with boric acid solu- 
tion (i : 30), and plugs of sterilized absorbent cotton should be 
placed in each nostril. 

The Ear. — The ear should be douched with boric acid solu- 
tion (1:30), and dried carefully with small wisps of cotton. 
Boric acid powder should then be blown gently into the external 
auditory meatus. A bit of sterilized gauze or absorbent cotton 
may be left in the meatus. 

The Scalp. — The directions for cleansing the scalp pertain to 
cases with or without scalp wounds associated with important 
cerebral symptoms. The whole scalp should be shaved, 
scrubbed with hot water and soap, with chlorinated soda 
solution (1:20), with boiled water, and then with corrosive 
sublimate solution (i : looo), and covered with a dressing of 
sterilized gauze that has been moistened in a solution of corro- 
sive sublimate ( I : 5000). The wound of the soft parts should 
be carefully irrigated with sterilized salt solution, and sponged 
and swabbed with great care w^ith corrosive sublimate solution 
(l : 5000). The swabs used should be tiny ones, so as to reach 
to the smallest recesses of the wound. Corrosive sublimate 
solution should not be allowed to touch the brain-tissue. 

The Mouth. — Thorough cleansing, with corrosive sublimate 
solution (i : 3000), of the teeth and tongue and all the folds of 
the mucous membrane about the lower and upper jaws is impor- 
tant. The swabbing of the tonsils and the posterior pharyngeal 
wall, the care of the nose and the ear, — these procedures will 
reduce to a minimum the chances of infection. The nose and 
mouth will require constant attention. The ear will require at 
least daily cleansing. The frequency of the cleansing required will 
depend very largely upon the amount of moisture and discharge 
from the part involved. If the packing of cotton soon becomes 
moistened, the douching should be repeated, and fresh, dr)' pack- 
ing should replace the old. If there is great restlessness, it 
may be necessary to restrain the patient, that he may not harm 
himself. This is done by means of a sheet folded and passed 
about the bed and body of the patient. 

Operative interference is demanded in penetrating or sharply 
depressed fractures, in all compound fractures, and in all simple 



36 FRACTURES OF THE SKULL 

fractures with symptoms of intracranial hemorrhage increasing 
in severity or distinctly localized (see Figs. 21, 22, 23). Opera- 
tion is undertaken in these cases for three distinct reasons : to 
insure cleanliness, to elevate and, if necessary, remove bony frag- 
ments, and to check hemorrhage. 
Tile details of operative treatment 
must necessarily be omitted. 

All cases of injury to the head, 
even cases of simple nondepressed 
fracture of the skull without symp- 
toms, arc to be watched with great 
care by trained observers for at 
least one month following the acci- 
dent, and then are to be seen at 
intervals for many months after- 
ward. Tiie reason for this pro- 
longed observation is that men- 
ingeal hemorrhage may develop 
in the immediate future, and that after an interval of months 
a brain-abscess may manifest its presence. 





In fracture of the base with pronounced symptoms, drainage 
of the fossa involved, whether anterior, middle, or posterior, 
should be considered. It has occasionally been of scr\ice. 



PISTOL-SHOT WOUNDS OF THE SKULL 



37 



Prognosis. — The prognosis of head-injuries is the prognosis 
of their complications and sequelae. Prolonged unconscious- 
ness is not usually dangerous in itself. Late unconsciousness is 
dangerous. The severity rather than the form of the lesion is 
to be made the basis of prognosis. The temperature is of great 
value in prognosis. By its persistent depression the danger 
from primary shock is gauged ; a little later in the course of the 
case the amount of hemorrhage is judged by it ; later still, its 
rapid and progressive rise will denote the magnitude or severity 




Fig. 23. — PcrpciuJicuIar lines from Ihe mastoid and from just in front of the ear include the 
motor area of the central convolutions. The fissure of Rolando is shown. 

of a meningeal or cerebral lesion. A temperature as high as 
105° F. is of grave prognosis. A sudden rise of temperature 
late in the progress of a case, probably due to a meningitis, or a 
continued subnormal temperature at any time after the reaction 
from the primary shock, is always an unfavorable sign. Symptoms 
often change suddenly in cases apparently doing well. One's 
prognosis must, therefore, always be guarded. 



PISTOLSHOT WOUNDS OF THE SKULL 

The treatment should be conducted on the same principles as 
the treatment of perforating fractures of the skull by a sharp 
instrument. The wound should be thoroughly explored and 



38 FRACTURES OF THE SKULL 

thoroughly cleansed ; this often calls for free incisions in the 
scalp. All loose fragments should be removed, including the 
bullet, if readily accessible. Drainage and strict asepsis are 
essential for the best results. Exploration and probing for the 
bullet should never be attempted by the physician in charge of 
the case. This should be a part of the operative procedure, and 
should be undertaken by the surgeon only under strictly anti- 
septic and aseptic precautions. 

LATER RESULTS OF FRACTURE OF THE SKULL 

Very little is known of these cases in this country. Dr. 
Bullard, of the Boston City Hospital, has contributed so valu- 
able a paper upon this subject that the results are here stated : 
Seventy patients were examined after having had fracture of the 
skull : 37 presented no symptoms when examined some time 
later. The most frequent consequences were headache, deaf- 
ness, dizziness, and inability to resist the action of alcohol on 
the brain. Out of 15 cases in which operation (trephining) 
was performed, 1 2 had no resulting symptoms ; in one case it 
was doubtful whether the symptoms present were due to injury ; 
in one case the symptoms were slight (headache rare, tension over 
the wound while lying in bed). The other case was deaf, but had 
no other trouble. 

Dr. Bullard concludes, so far as these statistics lead, that 
those cases in which trephining was performed have shown much 
better results, so far as the symptoms previously mentioned are 
concerned, than those in which no operation was performed. 

CLINICAL CASES OF HEAD INJURY 

The following cases, related in some detail, illustrate a few of 
the varieties of injuries to the head from a clinical standpoint : 

Case I. — A fall upon the head. — No visible evidences of injury. — An 
interval of consciousness follo7oed by unconsciousness. — Localizing signs 
of pressure. — Diagnosis y middle meningeal hemorrhage luith fracture 
of skull. — Operation. — Fracture and hemorrhage found. — Recovery. 

M. A. B , sixty-nine years old, a spinster, fell, upon being 

struck by a coasting-sled, one and one-half hours previous to the exam- 
ination. 

Kxamination. — She does not know of the accident which has be- 



ILLUSTRATIVE CASES 39 

fallen her. She talks coherently. She recognizes her sister. There 
is slight shock. The pulse is 64 and of fair strength; the respira- 
tion is 16; the temperature is 97.5° F. There is bleeding from the 
right ear. There is some dry blood about the nostrils. There is no 
visible external injury. There is no paralysis. All the superficial 
reflexes are present. The pupils are contracted ecjually and react to 
light. The patient is not very restless, although she talks consider- 
ably and affirms again and again that she is not hurt. 

The ears were washed out carefully and treated antiseptically. 

She vomited two or three times during the night. She was quite 
restless, moving and turning in bed. She slept two or three hours 
altogether. There were no evidences of intracranial pressure in the 
morning. At about noon of the second day she talked a little inco- 
herently. She did not answer questions as readily as in the morning. 

At 3 o'clock in the afternoon of the second day examination finds 
the pupils equal and reacting to light. She understands what is said 
to her, but does not talk coherently or distinctly. There is almost 
complete paralysis of the right arm. There is paresis of the right leg. 
The face is not paralyzed. The pulse has increased in rate to 85 and 
is particularly full and bounding. The knee-jerk is much less active 
upon the right than upon the left side. 

At 4.30 P.M., one and one-half hours after the previous observa- 
tion, all the symptoms were considerably intensified. The face was 
uneven, the wrinkles being most marked on the left. The breathing 
was becoming labored and almost stertorous. It was hard to arouse 
the woman. She moved the left arm freely. The right arm she moved 
slightly or not at all. There were no abdominal reflexes active. Bleed- 
ing from the right ear continued to a slight extent all day. 

A diagnosis of middle meningeal hemorrhage on the left side was 
made. Immediate operation was decided upon. 

Under ether anesthesia an elliptic incision was made upon the left 
side of the head, beginning just in front of the ear, and was carried 
up across the temporal muscle and down to the zygoma of the same 
side. A quarter-inch trephine was used. The hemorrhage was found 
to be from a branch of the middle meningeal artery, and from within 
the dura, which was lacerated. A large clot and much fresh blood 
were lying over the temporal and parietal regions. This blood was 
carefully sponged away. The middle meningeal branch was tied 
with a silk ligature. Gauze wicks were placed well down deep 
toward the base of the skull. The dura was not sutured. The bleed- 
ing vessels of the diploe were stopped with wax. The skin flap was 
replaced and sutured, leaving a small gauze drain down to the dura. 

The pulse was poor, and there was evidence of considerable shock 
at the conclusion of the operation. Proper stimulation with strych- 
nin and enemas of salt solution and brandy had a good effect. The 
temperature rose to 110° F. during the night, but dropped immedi- 
ately and gradually came to normal. 

The following day unconsciousness was present, the paralysis was 
unrelieved, the breathing was stertorous and puffing. 



\ 



40 



INJURIES TO THE HEAD 



The second day after the operation the gauze drain was removed 
and two smaller gauze drains were inserted. Some signs of con- 
sciousness ap])ear. She lakes notice of people coming into the 
room. 

The fifth day following the operation she notices friends. The 
paralysis is still present. 

The sixth day after the operation she moves the right leg a little. 
No articulate speech is present. Understands questions and grunts in 
answer to all questions. She can express no idea in words. 

The tenth day after the operation she moves the right arm. The 
mental condition is clearer. 

On the eighteenth day she moves the leg, and the arm has more 
power. 

The thirtieth day was an 
important one for the patient. 
She walked alone for the first 

One year after the accident 
the patient is found to be hav- 
ing occasional attacks of dizzi- 
ness, accompanied hy "falling- 
fits." She is ]>erfectly sane, 
and talks, often very well ; then 
there come times of difficuliy 
in talkinj;;, when she can not 
find the right word to ex]iress 
herself. Just after one of these 
attacks of fainting, etc., talk- 
ing is less easy. 

Three years after the opera- 
tion the following examination 
was made : The speech is thick, 
slow, and with effort. The fa- 
cial muscles of the left side are 
stiff and slightly drawn ; they 
do not move so well as on the 
right side. The left nasolabial fold is more accentuated than the right. 
The left eyebrow is lower than the right. The patient thinks that she 
can hear belter with the right ear than with the left. The right hand 
gets cold " and does not look natural." The right forefinger is often 
whiter than the other fingers of the right hand. It is difficult to pick 
up needles or pins with the fingers of the right hand. There is no 
increase in the wrist-jerks. The knee-jerk is slightly greater on the 
right side than on the left. 

The patient says she is enjoying excellent health, eats and sleeps 
well, and is out of doors much of the time. .She is taking brotnid 
of potassium regularly once a day in small doses. About once a 
month she has a fainting or "weak spell." These attacks are grow- 
ing less pronounced and less frequent. 




I 



FlS. 14.-C.I. 



ILLUSTKATIVI 



41 



This case illustrates the imporlaiit fact that after a severe head 
injury with almost no exterttal visible sign, the patient should he kept 
under very careful observation through the hours iinniediately succeed- 
ing the accident. Relative symptoms are of far greater importance 
in head injories than isolated observations. Bleeding from the ear as 
a syiMplom in head injuries does not necessarily imply fracture of the 
petrous portion of the temporal bone. Rupture of the tympanum 
may cause bleeding from the ear. There was no fracture of the skull 
detected after careful cJiaminaiion in this case. 

The interval of consciousness in this case was a somewhat short 
and hazy one. Immediately after the accident the woman was dazed, 
and at no time was she herself mentally. It is to be remembered in 
this connection that the interval 
of clear consciousness may be so 
masked by the symptoms of con- 
cussion as to be completely over- 
looked. 

Case 11.^ — An open tiepressed 
Jraeture of the skull. — Absence nf 
unconsciousness. — Paralysis of imr- 
half of the body. — Operation. — 
Recovery. 

This case illustrates that con- 
sciousness may be unim|)aired fol- 
lowing an injury to the head severe 
enough to cause paralysis. 

A boy. nine years old, was struck 
in the head by a brick falling from 
a height. He was seen immedi- 
ately after the injury and found to 
lie conscious. He answered ques- 
tions naturally. There was a large 
scalp-wound over the parietal bone 
and a little anterior to the parietal dtpMSMrtbo'i'ir.'"" """"' "' "'""'"' "' 
eminence to the right of the median 

line. The hone tjeneath the scaip-woimd was fractured and depressed 
into the brain-substance. The left arm and the left leg were com- 
pletely paralyzed to motion. The right pupil was dilated; sensation 
was present. The right upper eyelid dropped. There was a scar in 
the right cornea. Immediately after the injury the temperature was 
96° F., the pulse IV as 74, the respiration was 16. When examined 
one hour after the accident the pulse had fallen to 68, he had vomited 
once, and had been somewhat nauseated. 

The operation of elevation of the depressed fragments of bone 
was done under ether. The fragments of bone removed were about 
the size of a silver half-dollar. There was no fissure in the skull. 
The dura mater wa.s torn and the brain slightly lacerated. U[jon 
elevating and removing the depressed bone hemorrhage occurred from 
the vessels of the dura mater. The depressed bone was not replaced- 




ained by a wick of gauze. 



INJL'KIE! 



'The dura was left open and the cavity wa 
which was removed upon the third day. 

A few hours after the operation the boy was perfectly conscious as 
before the etherization, the pupilij were normal, and motion had 
returned in the paralyzed limbs. 

Three weeks after the operation a small, granulating wound remained 
and there was a slight tendency to hernia cerebri. 

Four months following the accident the boy's condition is as 
follows: The wound is nearly healed and continues to discharge at 
times. He walks naturally. There is no paralysis of arm or of leg. 
No mental symptom is present. 

The interesting and unusual fact in this case is that after a blow 
sufficiently severe lo cause a depressed fracture of the skull and 
paralysis of one-half of the body the patient remained conscious. 




The exact location of the injury to the head and brain is shown in 
figure 2$. 

Case III. — A bliiw upon the head. — Unconschusntss immediate. — 
Slight hulging of right eye. — Middle meningeal hemorrhage. — Frac- 
ture of skull. — Operation. — Recuvery. 

Examination found edema of the right temporal region. Uncon- 
sciousness present. An interval of consciousness was absent. Slight 
bulging of the right eye. 

Operation in the right temporal region, A skin-flap was made over 
the fracture and edematous area. A fracture was detected running 
from about the middle of the temiioral ridge an inch back of ihe 
coronal suture outward and forward across the squamous part of the 
tcmiioral bone to a Imlf-inch behind the ptcrion. 



ILLUSTRATIVE CASES 43 

The bone anteriorly to the fracture was depressed. The trej^hine 
was applied over the depressed portion behind the coronal suture. 
Upon exposing the dura no pulsation was seen. The dura was dark 
in color. A slight amount of extradural blood escaped. On follow- 
ing the fracture down to the base of the skull the dura was found 
lacerated, the anterior branch of the middle meningeal artery was 
torn, and blood-clot and lacerated brain-tissue were present. The 
anterior branch of the middle meningeal artery was tied and the 
hemorrhage ceased. The blood-clots were removed, the exposed area 
was cleansed with boiled water, and gauze drainage introduced. All 
the gauze was removed in four days. No unusual symptoms attended 
convalescence. Recovery was complete in three months (see Fig. 26). 

This case is of interest because no fracture was detected before the 
operation, and it was supposed that the bulging of the eye indicated 
an increase of intracranial pressure, which proved to be true. 

The method of operating was comparatively simple, in that the 
fracture was followed down until the bleeding vessel was found. This 
necessitated the free removal of bone below the trei^hine opening. 

There was no interval of consciousness in this case, and the condi- 
tions found easily explained its absence. The man was suffering from 
concussion and laceration of the brain as well as from intracranial 
pressure, and the interval of consciousness was obscured by the 
presence of the concussion. The recognition of an interval of con- 
sciousness is of very great importance. If, however, the interval of 
consciousness is not present, as ih the case reported, intracranial pres- 
sure from hemorrhage can not be said to be absent, for concussion 
attendant upon the injury may mask the interval of consciousness 
which might have been present had the injury been less severe. 



46 FRACTURES OF THE BONES OF THE FACE 

and the nasofrontal articulation upon the opposite side has been 
separated. Figures 29 and 31 show a case in which, by a direct 
blow squarely upon the nasal bones, the bones were separated 
and one was laid on one nasal process of the superior maxillary 
bone and the other was laid upon the corresponding bone. The 
septum was intact, as is shown by the persistence of the natural 
position of the tip of the nose. Figures 32 and 33 show a 
syphilitic nose, the septum gone, and the nose fallen in. The 
contrast in these two cases is instructive. 



I 




Symptoms. — Pain, swelling, crepitus, and deformity are usu- 
ally present. The subcutaneous swelling is often so considerable 
as to obscure deformity. Gentle pressure is often sufficient to 
detect crepitus in this fracture, when a firm grasp determines 
little or nothing. 

Complications. — Through infection of the internal or the 
external wounds suppuration begins, abscesses form, and necrosis 
of bone and liquefaction of cartilage may occur. Emphysema 
may be noticed if the fracture is open into the nasal cavity {see 



FRACTURES OF THE NASAL I 







FIK. 30 -C-se of fr 



48 



FRACTURES OF THE BONES OF THE FACE 



border. The septum may be dislocated from its attachment to 
the superior maxilla, and deviate into one nostril or the other like 
a curtain. The commonest dislocation occurs at the junction of 
the cartilage of the septum with the vomer and the ethmoid. 

Lesions of the septum due to fracture occur usually in the pos- 
terior two-thirds of the cartilaginous and in the anterior half of the 
bony septum. Fractures rarely extend through the septum to 
the posterior nares. In fractures of the nasal bones with little 
displacement the septum may show no changes. Even with 
considerable depression and comminution of the nasal bones, the 
septum as a whole may appear unchanged, the lesions of the 
septum being confined to bowing or tearing at the seat of frac- 
ture. When the nasal bones are much deviated, the free edge of 
the septum deviates with them. Fractures of the nasal bones 




Fig. 35. Fir. 36. !• ig. 37. Fig. 38. 

P'gs. 35-39. — The septum in fractures of llie nose (Mosher). 



Fir. 39. 



may occur alone or in combination with fractures of the septum. 
Severe cases of broken nose usually combine the two conditions. 
Fractures of the septum which admit of classification follow one of 
two types — horizontal fractures or vertical fractures. The vertical 
fracture is much the rarer. It may occur anywhere in the course 
of the cartilaginous septum, but when situated well back, is to be 
distinguished from dislocation of the cartilage. The horizontal 
fracture produces a gutter-like deformity roughly parallel with 
the floor of the nose. The convexity appears in one naris, the 
concavity in the other. Closely allied to these last two fractures 
are the sigmoid deviations, in which the relation to fracture is 
unsettled. They are so common that they are mentioned for the 
sake of completeness. The name describes them. They occur 
in the same two ty|)es as the angular variety. 



THE NASAL SEPTUM IN FRACTURE OF THE KOSE 



49 



Treatmeot. — The nasal cavity should be inspected by mirror 
and liyht to determine any lesion of the septum. Cocain anes- 
thesia is necessary for this examination. If a deviation is found, 
it should be corrected along with the correction of the external 
nasal deformity. For this, primary anesthesia will be needed, as 
the manipulation is e.\treniely painful. By external manipulation 
combined with elevation of the fragments and internal pressure 
with Roc's ele%>ati>r (sec Fig, 40) the deformity usually can be 
overcome. Any strong, narrow, and thin in.strunient will be of 
service as an elevator. For fractures high up with displacement. 




gauze packing carried well up will be required to retain the ele- 
vated bones. For lower deviations the Aseh tube will be needed. 
If the nose is crushed, it will be necessary to model the nose over 
the Asgh lube, one being placed in each nostril to preserve the con- 
tour and lumen of the nose. If there is no tendency for the de- 
formity to recur, the use of splints is not indicated. Care must 
be exercised to avoid sudden pressure on the nose from the rough 
use of the pocket handkerchief. In the treatment of these cases 
special cleanliness, perfect drainage, and frequent dressings arc im- 
portant. Ifthere is a recurrence of the external defoimily. localized 



so FRACTURES OF THE BON'ES OF TIIE FACE 

pressure may be exerted in various ways, all of which are more 
or less unsatisfactory. 

The tin splint fixed to the forehead by a circular plaster band 
is of service. This tin splint (see Fig. 41), made from ordinary 
sheet tin, consists of a forehead and a nasal portion. The nasal 
portion may be twisted or bent laterally to secure the desired 
pressure upon the nose, the counterpressure being obtained 
through the fixation secured by the adhesive plaster band. 
Repeated adjustments of this splint are needed to make the 
splint of continued efficiency ; with all care, 
however, the tin splint is not generally effec- 
tive. 

The use of adhesive plaster strips (after 
, ^ Davis) from cheek or malar bone to nose 
with small compresses is of limited value. 
Cobb's nasal splint, shown in figure 42. 
is e.xpensive, but is very satisfactory for 
making direct pressure upon the nasal 
bones. The splint is made of a band of 
.steel, fitted to the head like the hat-band of 
a hat. To this band are attached an arm and 
a pad with screw adjustment. A strap over 
the head and one beneath the chin prevent 
downward and upward di.splacement. 
""iki'i a'j^'i'i'eli. ^'" ""*'' Coolidgc's Splint (see Fig. 43). — This 

consists of a till pad for the forehead with 
strap encircling the forehead for the retention of the pad in posi- 
tion. To the lower border of the pad are .soldered two wire 
arms upon which slide two .small felt pads. The arms can be 
bent .so that counterpressure may be obtained upon the firm 
parts of the face, while direct pressure with the other pad is 
brought to bear upon the nose. This splint is inexpensive and 
is efficient. 

The na.sal cavity should be cleansed at least twice daily with 
antiseptic douches. Seller's tablets, one tablet dissolved in a 
<[uarter of a tumbler of warm water, used with the ISirmingham 
glass douche, make a .satisfactory wash. The external wounds 
sliouSd he dressed according to general surgical principles. It is 




TlIK NASAL SEPTUM IN FKACTUKE OF THE NOSK 5 I 

well to remember in this connection lliat suppurating wounds do 
far better if dressed frequently than if left to accumulate purulent 
discharges. 

After a blow upon the nose, even if there is no immediate de- 
formity, the nose should be examined to determine tlie presence 
of swelling upon the cartilaginous septum. Even a slight blow 
upon the nose may cause a hematoma of the cartilaginous septum 
(see Fig. 44). This hematoma is liable to become infected and 
to suppurate. Considerable destruction of cartilage may follow, 
resulting in marked disfigurement of the nose. 




The involvement of the base of the skull adds a serious cle- 
ment to an ordinary simple accident (see Figs. 16, 18), 

The prognosis as regards the resulting deformity must always 
be guarded. Union usually takes place within two weeks of the 
accident and is firm in one month. In treating fracture of the 
nose it is important to be ever mindful of hematoma of the septum, 
and abscess of the septum resulting from it. The external de- 
formity that follows fracture does not tend to increase, but the 
internal deformity does. It is, therefore, of even more impor- 
tance to correct the internal deformity than the external. Unless 
both are corrected, the nose may be .straight but obstructed, 



52 FRACTURES OF THE BONES OF THE FACE 

FRACTURES OF THE MALAR BONE 

Examination. — Palpation of the malar bone is somewhat 

difficult. The best method of doing it is to stand behind the 

sitting patient {see Fig. 45), and to feel both malar bones at the 



Fin. 43.-C(«lidg. 




same time — the left one with the left hand, the right one with 
the right hand. The malar process of the superior maxilla is 
felt inferiorly by pushing the skin of the cheek upward. The 
orbital part of this process is felt superiorly at the middle of the 



FKAurUKES OF THE MALAR BONE JJ 

inferior border of the orbit. Following the orbital margin out- 
ward and upward, the orbital border is palpated up to the frontal 
process. Following the malar process of the superior maxilla 
backward, the free inferior border of the malar is felt continuous 
backward with the zygomatic process. Starting on the frontal 
process, the posterior border of the malar may be palpated down- 
ward and backward to the upper border of the zygomatic process 
of the temporal bone. The inferior surface of the malar may be 
felt by placing the fingers, palm upward, in the superior sulcus 
of the cheek and following backward until the coronoid process 
of the lower jaw is felt. In the case of a fracture that is as often 



FIk. iJ.-Propwt 




unrecognized as is this one it is important to be very familiar with 
the details of the outline of the bone. 

Symptoms. — Fracture of the malar bone is cau,sed by a severe 
blow upon the cheek. It is rather unusual to find a fracture of 
the body of the bone. More often there is a fracture of one of its 
processes, the line of fracture being continuous with a fracture of 
some adjoining bone. The malar is depressed as a whole, or tilted 
inward toward the zygomatic fossa because of a loosening of one 
or more of its articulations or because of a fracture or crushing 
of the su[)crior maxilla. The deformity consists of a depression 
to ihe outer side of and below the eye. The line of fracture or 
separation can snmelimes be palpated. Mobility and crepitus 
are rare!)' obtained. If the depression of the malar or of an asso- 



54 



FRACTURES OF THE RONES OF THE I'ACK 



dated fracture of the zygomatic arch impinges upon the space in 
which the coroiioid process moves in the opening of the mouth, 
the motions of the lower jaw will be restricted (see Fig. 46). 
The limitation of motion of the lower jaw may be temporary or 
permanent, depending upon whether it is due to hemorrhage 
and swelhng or bony pressure. The coronoid process of the 
lower jaw may be fractured by the same force which fractured 
the Jtygoma or malar. Localized subconjunctival hemorrhage 
may appear if the orbit is involved. If the floor of the orbit is 
fractured so that the infra-orbital nerve is implicated, there will 
appear prickling sensations tliroughout the area of distribution 



HB.tl-NQM 







of that nerve — namely, along the upper gum, the skin of the 
cheek, of the nose, and of the upper lip. 

Treatment. — It i* oftcntitne-t impossible completely to correct 
the d*-fonnity except by ojicrative means. If any inierfcrcucc with 
the mov-cmcnis of the lower jaw (>cr,si.*ls after the acute swelling 
flisappe^rs, — that i>. after two weeks. — or if it is vcn,- evident at 
the outset that the liniitHtion of motion is due to the depres»on 
i*f bt^inc. then operative intcrfcrcnce is demanded. Rcforc a cut- 
ling operation is re.iortcd lo an jnetthclic should be adminisieicd 
and an aiiempt m.vlc by (wrSMirc with a blunt instrument under 



FRACTURES OF THP: SUPERIOR MAXILLA 55 

the malar from inside the cheek to raise the depressed fragment. 
If this can not be effected, a small incision should be made at 
the most advantageous point, avoiding making the fracture an 
open one. Through this incision access is gained directly to 
the bone. By means of a narrow periosteum elevator, retractor, 
hook, or a screw elevator, the fragment can be raised into its 
normal position. 

Union occurs in two weeks. There is no tendency to a 
recurrence of deformity, therefore no retentive apparatus is 
necessary. 

The surgeon is not uncommonly asked to remove the slight 
depression attending a healed fracture of the malar bone. This 
may be most difficult. It should be attempted, however, as in 
fresh injuries, without a cutting operation, or by an incision 
within the mouth through the mucous membrane, or, if neces- 
sary, by an external incision. 



FRACTURES OF THE SUPERIOR MAXILLA 

Fracture of the superior maxilla occurs so frequently from a 
bicycle injury that it may properly be called the bicycle accident. 
The blow causing this fracture is usually not in the direction to 
damage the base of the skull, but to tear the bones of the face. 
The nasal process of the superior maxilla may be broken when 
the nasal bone is fractured. The anterior wall of the antrum 
may be broken by the same blow. The alveolar process may be 
broken. The damage to the bones of the face, and particularly 
to the upper jaw, is associated with injuries to various con- 
tiguous bones. Blows result in many irregularly disposed frac- 
tures. 

The diagnosis is made by inspecting the mouth, nose, and 
cheek. These fractures being open, there is little difficulty 
in detecting them. A very careful inspection should be made, 
with an anesthetic if necessary, to determine the extent of the 
lesions. Emphysema and great swelling of the face occur. 
There may be no wound of the skin. Whether the injury to the 
upper jaw is associated with injury to the base of the skull or 
not can be determined in the absence of visible signs by the 



56 FRACTURES OF THE BON^ OF THE FACE 

subsequent development of cerebral symptoms. Necrosis of bits 
of bone is rare after upper-jaw fractures, excepting fracture of 
the alveolar border. Hemorrhage may be considerable, but it is 
easily controlled by pressure. The infra-orbital nerve may be 
damaged. The lachrymal canal may be temporarily compressed 
or obliterated. 

Treatment. — If there is no wound of the skin and much 
depression of the jaw, so that the face looks knocked in, it will 
be necessary to devise some method of elevating the depressed 
bone and of restoring the normal contour of the face. To avoid 
a visible scar, the mucous membrane should be incised on the 
inner side of the upper lip, and the fragments elevated by an 
instrument introduced through the incision. As little bone as 
possible should be removed, so as to leave sufficient support to 
the soft parts of the cheek after healing. Only thus can a fall- 
ing in of the cheek be prevented. If access through the mouth 
is unsuccessful, it may be necessary to incise the skin over the 
fracture. This, of course, is to be avoided if possible. The 
accidental wounds should be thoroughly and vigorously swabbed 
with a solution of corrosive sublimate (i : 5000). The use of 
tiny swabs of gauze held by forceps will facilitate this procedure. 
The avoidance of sepsis in these cases is of paramount impor- 
tance. If the wounds become septic, there is great danger of an 
extension of the inflammatory process to the deeper parts or 
even to the meninges of the brain. Lacerations of the soft parts — 
lips and cheeks — ^may have their edges approximated to secure less 
scar than if left unsutured. Loose small bits of bone should be 
removed with forceps and scissors. Loosened teeth should be left 
in good position in their sockets. A mold of the lower jaw should 
be taken in composition or plastcr-of- Paris, if possible, by a com- 
petent dentist, and a rubber splint made from this mold to fit 
the teeth and alveolar border of the lower jaw. When this 
splint is applied, its upper surface may be brought up against the 
teeth of the upper jaw and held snugly in apposition by an 
external bandage, as in fracture of the lower jaw. This splint 
will materially assist in reducing the displacement of the upper- 
jaw fragments. It may be possible for a dentist to apply a splint 
directly to the alveolar margin and teeth of the upper jaw. If 



FRACTURES OF THE SUPERIOR MAXILLA 57 

this is possible, greater security of fragments will be obtained 
than by any other method of treatment. The physician may 
greatly assist in immobilizing the fracture, until a permanent 
dressing is applied, by making quickly a temporary splint of 
dental wax or dental composition, and applying it to the teeth and 
alveolar margin of the upper jaw. This composition is softened 
and made malleable by placing it in hot water ; it can then be 
molded on the jaw, and in two or three minutes is firm (see 
Fracture of the Lower Jaw). 

After Care. — Six weeks to two months will be necessary to 
insure firm union and freedom from complications. The swell- 
ing associated with the reparative process will gradually subside. 
Great care must be exercised in the nursing of the patient after 
this injury, as the element of shock is an important one to be 
considered. Strychnin sulphate (^^^ of a grain), given two or 
three times daily, is indicated if there is evidence of shock follow- 
ing the accident. This should be continued each day for as long 
a period as shock is evident. 

Prof)er nourishment under these adverse conditions of adminis- 
tration is to be given careful consideration. Liquids alone are 
to be used the first week. These may be given by enemata 
or by the mouth with a tube to the back of the pharynx or 
by a nasal tube if necessary. Nasal feeding is simply and easily 
carried out. A rubber tube three feet long is needed, to one 
end of which is attached a funnel and to the other end a soft- 
rubber catheter, in size No. lo F. The patient is half reclining 
while the surgeon introduces the catheter into the nose until it 
passes well back and down into the pharynx. The funnel, some- 
what elevated a foot or more above the patient's head, is kept 
filled with the liquid nourishment so that its contents run slowly 
into the esophagus. A plug of absorbent cotton, moistened with 
a four per cent, cocain solution, and placed in the nose for a few 
minutes before feeding, facilitates this procedure. 

The nose and mouth should be douched and swabbed regu- 
larly each day. This should be done after feeding the patient, 
and oftener if necessary in order to avoid all odor from the 
mouth. Listerin, two teaspoonfuls to half a cup of water, is a 
satisfactory wash for this purpose. The profuse dribbling of 



5ti FRACTURES OF TilE LOXES OF THE FACE 

saliva which attends this fracture demands drainage of the mouth 
by wicks of gauze placed in the cheeks and gauze handkerchiefs 
for keeping the surrounding parts dry. Wiring the fragments of 
bone may be necessary if there is great displacement. Wiring 
the alveolar border to the body of the jaw may be demanded. 
Suture of the bony fragments with chromicized catgut will often 
steady them in position until union takes place. 



FRACTURES OF THE INFERIOR MAXILLA 

With the exception of the superior internal surface of the 

articular process, practically the whole of the inferior maxilla 

may be palpated. Fractures of thi. mfenor maxilla are caused 




by direct violence. The seat of the fracture will be deter- 
mined by the force and direction of the blow, by the location 
of the teeth in the jaw (the jaw being weakest where the teeth 
have been Inst), by the pre.seiice of any foreign body between 
the teeth (such as a pipe), and by the presence or absence of 
mu.scular relaxation. I'ractures of the base of the skull 
through blows on the jaw are more likely to occur if the mouth 
i.s open. I'racture.s of the body of the bone are common ; of 
the ramus behind the molar teeth, rather uncommon ; of the 



FKAUTUKES OK THE INFERIOR MAXILLA 59 

condyloid and coroiioid processes, very unconimon. The seals 
of fracture of the inferior maxilla are shown 
in the accompanying illustrations (see Figs. 
47. 48. 49. so)- 

Excepting those of the condyloid and 
coronoid processes, fractures of the inferior 
maxilla almost always open into the mouth. 
They occasionally open through both the 
mucous membrane and the skin. 

Examination.— Even when the patient 
c.in not open the mouth sufficiently to admit 
the examining finger, palpation of the body Lm'eS'^ioweih!"' ' '"'" 
and ramus of the jaw, with one finger in 
the cheek and another finger upon the chin, will often reveal the 
seat of fracture. 

Symptoms. — Pain, crepitus, and abnormal mobility may be 





;scnl. Immediate swelling of the gum appears at the seat of 
^ fracture. TL-eth contiguou.s to the fracture of the body of 
: maxilla will be either displaced or loosened. The displace- 



6o 



FHACrUKES OF TilE HONES Oi" TE)E FACE 



nient of the fragments in fracture of the body and ramus will be 
most easily delected by noticing the differences in level of the 
teeth on each side of the fracture (see Fig. 50). The face 
appears swollen. After a few days the submaxiliary and adjoin- 
ing cervical lymphatic glands become enlarged. The salivary 
secretions are increased in quantity, and because of the disincli- 
nation to painful swallowing, the saliva dribbles out of tlie mouth. 
If the fracture opens into the mouth, suppuration often appears 
and pus mingles with the saliva. Particles of decomposing 
food between the teeth and in the spaces outside the jaw 




within the cheeks add to the bacterial pabulum. The odor from 
this mass of foul material i.s characteristically penetrating and 
offensive. After a few weeks necro.sis of bone may occur at 
the seat of fracture, with abscess formation. A discharging 
sinus pointing to the disease appears. These cervical abscesses, 
often difficult to manage, occupy the region of the body of 
the jaw. The submaxillary and upper carotid triangles may 
be tilled by a brawny infiltration associated with necrosis of a 
fractured jaw. On the other hand, with proper treatment and in 
less difficult cases the course of tlie healing process is simple 
and of easy management. Suppuration i.s prevented. There 



FRACTURE OF THE liODY OV THE JAW OI 

is no necrosis, and the repair of the fracture takes place un- 
hindered. 

Treattneot. — The primary object of treatment is the preser- 
vation of the natural ahntmcnt of liie ttreth. 'I'iiis object is 
attained by a complete reduction of the fragments of the frac- 
tured bone. If a tooth interferes with the perfectly accurate 
closure of the mouth, and if the adjustment of the fragments is 
prevented by the position of the tooth, it should be extracted at 
once. Ordinarily, there is but slight displacement. This dis- 
placement can be corrected by digital pressure upon both frag- 
ments. 




Fracture of the Body of the Jaw. — The simple fracture of 
the body of the jaw without mucli displacement may be tem- 
porarily treated by the four-tailed bandage, which should hold 
the teeth of the lower jaw closely in apposition with the corre- 
.sponding teeth of the unbroken upper jaw. As soon as prac- 
ticable, a dental splint of rubber or aluminium should be made 
and applied by a dentist. This aluminium splint fits the crowns 
of the teeth some distance upon each side of the fracture, 
and holds the fragments firmly in apposition (see Fig. 51), It 
also permits of opening and shutting the mouth. The old-time 



62 FRACTURES OF THE BONES OF THE FACE 

four-tailed bandage and extradental splint of millboard (see 
Fig, 52) is inefficient. As a permanent dressing it should be 
discarded. It is useful only as a temporary support. In the 
simple cases, in the absence of a competent dentist to make the 
aluminium or rubber dental splint, a splint of silver wire passed 
around many teeth upon each side of the seat of fracture is 
often efficient. The method of wiring two adjoining teeth, those 
on each ^ide the fracture, is unsatisfactory in that the strain 




loosens the teeth and displacement is easily effected (sec Fig. 

53)- 

Fracture of the body toward the angle of the jaw, through the 
region of the molar teeth, is often less easily held in good posi- 
tion. To the dental rubber splint the dentist should add lateral 
arms of wire, held in position by a posterior strap (see Fig. 54). 
These wire arm* increase the efficiency of the dental splint, for a 
bindage is passed rmder the chin between ihc wires and thus 



FRACTURE OF THE BODY OF THE JAW 63 







IoriBurc5J(M..rliitliF|. 



64 FRACTURES OF THE BONES OF THE FACE 






1 




1 


9 -^ j^^K^ 



FIk. K.— SamciMii'ii'^'ni'ifieuresfi: : 



: OP TllK ]101>V OF Tlili JAW 65 




Fle,S9.-SMevlcwofspli"l (««' 



60 



FRACTURES OF THE BONES OF THE fACE 



steailies the jaw by upward pressure (see l-'ig. 55). If a still 
more efficient method is demanded, the dentist uses an extra- 
dental chin-piece of metal (see Fig. 56), which is adjusted by 
screws so that firm, evenly graduated pressure upon the fractured 
jaw is maintained between the inside dental splint and the out- 
side chin-piece. While wearing this splint the mouth can be 
opened easily (see Figs. 58. 59, 60). 

The Making of the Dental Splint. — If an impression is de- 




sired of the crowns of the teeth and the adjoining gum, it is best 
made by using the modeling composition manufactured for the use 
of dentists. The necessary amount of the composition is dropped 
into hot water ; when soft, the composition is put into the metal 
impression-cups (see Fig, 6 1 ). The surface of the composition is 
warmed by holding it over a Ramc or holding it again in hot water ; 
then the impression-cup containing the softened composition is 
placed in the mouth and the impression made. Immediately upon 
the removal of the mold from the mouth the composition cools 



THE MAKlNt; OF THE HENTAL SPLINT 6/ 

and hardens. From this mold is made the duplicate of the 
alveolar border and the leeth in plaster-of-l'aris (see Fig, 62). 
The lines of fracture arc clearly indicated upon the plaster casl. 



Flj(.6 




With a fine saw the cast is cul upon these Mnes and the lower 
teeth are articulated with the plaster cast of the upper jaw, which 
has been made. Piaster cream is used to hold the sawed por- 




tions together. In other words, the fnictiire has been repro- 
duced and reduced in plaster-of- Paris. Both upper and lower 
casts are then put upon an articulator (see Fip;. 63). A vulcanite 



6« FKACTURES OF TBE BOKES OF THE FACE 

splint is made frotn this reconstructed lon-er jaw, and when this is 
applied to tbe fractured jau- as an interdental splint, the defonnitV' 




is corrected and comfortably prevt'nted from recurring (s« 
64.65). 



Figs. 



FiB. a^^tUni-f abbd 




Practorc at the Rames of tbc Inferior Maxilla Just Behind 
tbe M€>lar Teeth. — The displacement is difficult to corrccL The 



TREATMENT 69 

fracture is usually oblique from before backward and downward. 
as seen in the tracing {see Fig. 48). The body of the jaw drops 
downward and bacl< ward and the ramus slides forward. No dental 
splint is practicable, because there are no teeth on one side of the 
fracture to which the splint could be attached. Etherization 
will often be found helpful, and at times necessary, in the reduc- 
tion of this deformity. Reduction is accomplished by pressure 
backward upon the ramus with the thumb in the mouth and a 
simultaneous lifting forward and upward of the body of the jaw. 
Reduction is maintained by an outside pad and metal chin-piece 
and a buckle and strap splint. This buckle and strap splint 




(see Fig. 67) is o( great advantage because it is easily adjusted, 
and the amount of pressure can be graduated. It is of impor- 
tance to note here that even after this fracture has been reduced 
and is at the outset apparently held reduced by the bandage, j'et 
it will usually slump away a little and at the end of the first 
twenty-four hours after setting the fracture the fragments will be 
found to be partially unreduced. Upon a second application of 
pressure by tightening the bandage the fragments will come into 
apposition with comparative ease. By careful and repeated ad- 
justments of the bandage and padding, after a week and a half 
even in the most obstinate cases, the jaw will be found to be in 
[food position, with the teeth articulating. 



70 PR ACTt'k F-- OF TirE BONF,- OF THE FACE 

Fracture of the Body of the Ramus upon the Same or Oppo- 
site Sides of the Inferior Maxilla. — The fracture i~ diRicuU to 
hoifl fixc'l. In this case the dental aluminium or rubber splint 
will be needed, together with the fuLside pressure made by the 
metal chin-piece. 

Whichever meth'^ of treatment is adopted, the fracture at 
first should be inspected daily in order to insure accurate adjust- 
ment of apparatus. The mouth and teeth should be kept 
scrupulously clean. When practicable, the teeth should be 
Kcalcd by a dentist t^efore permanent apparatus is applied. 
Brush and swab with some mild anti.septic wash, such as IJs- 




tcrin, one part in four of water, should be used after taking nour- 
ishment and before bedtime and upon rising in the morning. 
The iif]ui(t nourishment of the patient should be given throuj^h 
a glass tube at first. If it is unwise to open the mouth, a 
rubber catheter may be u.sed behind the molar teeth. The rubber 
cathelcr with a siphon attached is a very satisfactory method of 
fcffling. The genirral health should receive careful attention. A 
patient with this fr,i<:luro is a]>t to become despondent and anxious 
about himself, parliriilarly if suppuration e.vists. The repeated 
sn-illowint; of fnui sccretiiins inijKnrsthi; appetite, causes indiges- 
tion and grnrndly i»"..i- health. The lo.ss of variety in diet favors 
this coridilion. ' )ut-of-door exercise, plenty of sleep, a mild tonic. 



such as ferratetl elixir calisayi and sulpiiate of strychnin, and a 
little wine, will all assist in restoring and maintaining good 
health . 

Abscesses which appear should be treated by incision, evacua- 
tion of their contents, drainage, and antiseptic dressings. Bits 
or necrosed bone should be removed. Union in fracture of 




the jaw occur.-; ordinarily in from three to five weeks. The 
apparatus is to be w<irn until the union of the fracture is firm. 

Fracture ol the coronoid and articular processes is to be 
treated by simpli: immobilization of the jaw. 

These various methods of immobili7.ation mentioned may fail 
in some unusual fractures ; if so. suturing of the fracture through 
the bone with .silver wire or other material should be undertaken. 



CHAl'TKR III 

FRACTURES OF THE VERTEBRAE 

Anatomy. — The forked spine of the axis may be felt beneath 
the occiput uj)On deep pressure. The spines of the third, fourtli, 
and fifth cervical vertebr.x recede from the surface, and can not 
be felt distinctly. The spines of the sixth and seventh vertebra: 
project distinctly, and can be palpated. At the bottom of the 
furrow in the middle line of the back arc felt the spines of the 
dorsal and lumbar vertebr.x. The spinous processes from the 
seventh cervical to the third sacral are subcutaneous. The 
spinal cord extends from the lower edge of the foramen magnum 
to the lower border of the body of the first lumbar vertebra. 
The phrenic nerve leaves the spinal canal between the third and 
fourth cervical vertebra;. Hy palpation through the mouth (see 
Figs. 69, 70) the bodies of the vertebra- may be felt down to 
about the upjier border of the body of the fifth vertebra. The 
cervical enlargement of the spinal cord is more marked than 
the lumbar swelling. It commences at the third cervical ver- 
tebra and ends at the second dorsal vertebra. The lumbar 
enlaiKement commences at the level of the ninth dorsal vertebra 
and reaches to the twelfth dursiil vertebra. The spinal cord is 
well protected from injury (sec Fig. 71). 

The vertebni; commonly fractured are the fourth, fifth, and 

sixth cervical, the twelfth dorsal, and the first lumbar. The 

njury to the vcrlebrii- is ciiused in one of three ways : by a 

upon the arches of the vertebra;, fracturing the 

f a fall upon either the head or the buttocks, crush- 

itodics of the vcrtcbnt ; or by forced flexion or extcn- 

, causing; a dislocation with or without fracture 

End articular pR.»:esses. More than one-half of 

ical verli'bne arc fractures of the spinous 

hinls of the cases of fracture of the 




dorsolumbar vertebras are fractures of the bodies of those ver- 
tebra. A dislocation without fracture may occur in the cervical 
region ; it is rare in other regions of the spine. 




It is important in localizing spinal-cord lesions to know the 
point at which each nerve arises from the spinal cord, because 
the point of orij^in does not correspond with that at which the 



74 



ruACTvnfs of the vertebrk 



nerve emerges from the spinal canal (see Fig, 73). The point 
of origin is higher than the point of exit. Many of the nenes 
pass obliquely from the cord, lying still within the vertebral 
cjnal after leaving the cord (see Fig. 73). These nerves within 
ihe canal are liable lo pressure from the vertebral fracture. For 
example, a fracture of the eleventh dorsal vertebra would injure 
not only the con! at iliis level, but in addition might injure the 








last dorsal and upper lumbar nerves. The lower the spinal 
nerves arise, the longer is their intraspinal course. The points 
of origin of Uie spinal nerves from the cord with reference to 
Ihc spines of the vertebra; arc as follows (see Fig. 74) : The 
eighth cervical nerve* ari.se from the cord between the occiput 
and the sixth cervical spine. The upper six thoracic nerves 
arise from the cord between the sixth cervical fspinc and the 



EXAMINATION 



/ :> 



fourth dorsal spine. The lower six thoracic nerves arise from 
the cord between the fourth and tenth dorsal spines. The five 
lumbar nerves arise from the cord opposite to the eleventh and 
twelfth dorsal spines. The five sacral nerves arise from the 
cord opposite to the first lumbar spine. No hard-and-fast rule 
at present is applicable to the enumeration of the lesions follow- 
ing the dislocations of definite vertebra;. From the combined 
experience of such clinicians as Gowers, Kocher, Putnam, Den- 
nis, Walton, Bullard, Thomas, and others the following table is 
constructed, and is valuable for practical use : 



TABLE STATIN(; LESIONS FOLLOWING INJURY TO DEFINITE 

VERTEBR/K. 



Spinal 
Sbgments. 

Cervical : 



MuscLKS Involved. 



First, second, 
third, . . . [Death]. 



Fourth, . 
Fifth, . . 
Sixth, 
Seventh, 
Eighth, . 

Dorsal, . . 



VkRTKBR/E 

Dislocated. 



Skull on atlas, atlas on 
axis. 



Reflexes In- 
volved. 



. Diaphragm. 

. Biceps, supinators, deltoid. 

. Pronators, triceps. 

. Extensors, flexors of wrist. 

. Intrinsic muscles of hand. 

. Abdominal muscles. 



Axis on third cervical. 

Third on fourth. / p^pj, j^ 3^^,, 



Fourth on fifth. 
Fifth on sixth. 
Sixth on seventh. 



} 



and reaction 
sluggish. 

Epigastric, ab- 
dominal. 



Lumbar : 
Second, . . . C remaster. 



Adductors. 
Outward rotators. 



Third, \ 

Fourth, ; . . 
Fifth 1 Extensors of thigh, 

' of knee. 



Eleventh on twelfth Cremasteric, 
dorsal. 



flexors ^^'^'^^^ ^" ^^^^^ lumbar. Gluteal. 



Sacral : 

First, .... Extensors of fool. 
Second, third, 

fourth, fifth. Perineal muscles. 



First on second lumbar. Plantar. 



Ankle-clonus. 



Examination of an Injury to the Spine. — Four questions 
are to be answered : What was the nature of the accident ? What 
does palpation of the spine reveal as to the nature of the lesion ? 
What is the level of the lesion ? Is the lesion partial or com- 
plete ? 



76 



FRACTURES OF THE VERTEBR.K 



General Symptoms Common to Fractures of the Ver- 
tebras. — Signs of shock will be present. At the seat of the bony 
lesion will be found pain, tenderness, abnormal mobility, crepitus, 
and deformity. The deformity will ordinarily be a backward 
bending, or kyphosis, of the spinal column at the seat of frac- 
ture, unless there exists a unilateral dislocation, when the deform- 
ity will be irregular in appearance. The chief symptoms depend 




.& cervical 

nerves- 

J- 6 dorsal 
"Tierves* 

.Xower o 
dorsal nerves- 

.Slutnbarn- 
_5 sacral n- 



; 



V 



Fi^. 74. — Dias^ram of spinal origin of nerves, according to the level of the spinous processes. 



upon the injury done to the spinal cord. In general it may be 
stated that motor and sensory paralysis, either partial or com- 
plete, will be found up to the level of the lesion. The reflexes 
are ordinarily increased below the lesion. Retention, and later 
incontinence, of urine and feces will exist. Cvstitis of the 
urinary bladder will develop at an early date. Bed-sores and 
great sloughing areas (^f skin upon dependent parts will be dis- 
covered early. Priapism occurs. 



SYMPTOMS 



n 



Sjnnptoms of Fracture of the Different Regions of the 
Spine, the Cord Being Involved. — Injuries to the Last Dorsal 
and Lumbar Vertebrae (see Figs. 75, 76, tj^ — The spinal cord 




Fig. 75. — Fracture of the twelfth dorsal vertebra, Aiicsthcsia to the height of the anterior 
superior spinous processes in front. Second lumbar nerve involved. 





Fig. 76. 



Fig. 77- 



Figs. 76, 77.— Fracture of the twelfth dorsal vertebra without involvement of the first lum- 
bar nerve-roots, the ilioinguinal, iliohypogastric, and external cutaneous nerves not being 
involved. 



ends opposite the lower border of the first lumbar vertebra. Any 
pressure at this point or below will involve the cauda equina in 



y' 



FkAcr^kKs OF WW. VKkrKr;R.K 



f;wt\f\ or in p;^irt /"see Fi;(s. 78, 79). Local evidences of the 
h'/rty Usion=v may \>(: present. The paralysis of the legs may 
\tt'. pHrti;il or complete. The rinesthesia of the lower h'mbs 
i-; partial r;ither than complete and up to the level of the 
bony legion. Retention or incontinence of urine and feces 
exiHtN. Th'- paraly/ed muscles nipidly become wasted. Con- 
=*tant p;iin ;ind hyf>eresthesia may be present both above and 
fyJo'A^ the legion. The patellar and plantar reflexes are usually 

I h'* pro(^nosis is not alto<^ether unfavorable to recovery. 







\i 



\Vr 




I'lK. 7H. 



^'iK- 79- 



Kln«. 7H, 7g.— Ililury In Ihe rmnltt rqiiiiiH, \vhl»li lm«» lnvi>lv<'«l the third sacral nerves. Frac- 
tlirp (if the fllM liimlmi vertebra «r the nci-oiid hiinbar vertebra. 



Partial recovery, so as to be able to move about, is probable. 
Later, muscular contractures will exist in the lower limbs, which 
im|Kulo walking. If at the end of six weeks evidences of begin- 
ning recovery do not appear, or if reiovery once begun has ceased, 
it will Ik* wise to operate upon injuries to the cauda equina. 

Injurtesi to the Dorsal Vertebra* (second to the eleventh) (see 
Kijj. J^oV — The simple distribution K>!i the spinal dorsal nerves 
makes the inteq>reiatit>n of injuries to this rei;ion much easier 
than similar injuries to the cervical or lumlur reuii>ns. The arms 
e^ca|)C jKiralysis, The nuUor and sensoi y |\ir.dysis extends ordi- 



SYMPTOMS 79 

narily to the height of the bony lesion. In a few cases in whicli 
the nerve-trunks within the canal are not implicatetl the level of 
the paralysis will be lower than the lesion. The patellar reflexes 
are increased. If the patient recovers, there will be spastic 
paralysis if the injury is above the lumbar enlargement. If the 




lumbar enlargement is involved, there may be great pain in the 
legs. 

Injuries to the Cervicodorsal Region, Opposite the Cervical 
Enlargement of the Spinal Cord. — The arms escape paralysis, 
perhaps, at first, but become involved after several days. The 



So 



FRACTUKES OF THE VERTEBK.i: 



panilysis is often partial. Respiration is diaphragmatic only. 
I'ain in the arms is quite constant. If the sixth vertebra is di.slo- 
cated upon the seventh, the intrinsic muscles of the hand will be 
paralyzed. If the fifth vertebra is dislocated upon the sixth, 
there will ap]>ear a characteristic position of the upper extremi- 
ties (see Fig. 8i) : abduction of the arms, flexion of the forearms, 
with rotation outward of the whole extremity. If the injury is 
above the sixth cervical vertebra, there will be anesthesia of the 
entire limb excepting the outer side of the arm and forearm and 
the radial border of the thumb. The attitude after lesions 
between the sixth and seventh cervical vertebra; is shown in 




figure 82. The characteristic attitude in lesions between the 
sixth and seventh cervical vertebra; is also shown in figure 82, 

Injuries to the Midcervical Region. — A lesion of the fourth 
or fifth cervical vertebra will involve the phrenic nerve. The 
diaphragm will be {Mralyzcd. Death will occur within a few 
hours. 

Injuries to the First Two Cervical Vertebne {xc Vi^s. 84, 
85). — If the displacement is slight, life may be spared until 
sudden displacement occurs or a sccondaiy myelitis causes 
death. Cases of recovery are recorded. Death usually occurs 
instantly. I'crhaps one person in fifty thus injured recovers 
(Cowers). 



PKOtiNOSIS AND TREATMENT 8 I 

Prognosis. — The prognosis depends upon the amount of in- 
Jury to the spinal cord. The prognosis is less grave than it was 
thought to be a few years ago. There is a probability of saving 
a limited number of cases. In general, the nearer the fracture 
approaches the medulla oblongata and the foramen magnum, the 
more serious does the outlook become. Patients with fracture 
in the dorsal and lumbar regions die in the course of months 
from cystitis, pyelitis, and exhaustion. Patients with fractures 
in the upper dorsal and lower cervical regions die in a few days 
or weeks from hypostatic pneumonia. Patients with fractures 




high up in the cervical region die instantly or in a few hours 
from shock and direct pressure upon the medulla oblongata. 

Treatment. — The object of treatment is to relieve the cord 
from pressure and to immobilize the fracture. The cord will 
be uninjured, slightly injured, or injured seriously. If the 
cord is uninjured, the bony parts may be left untouched or 
they may be replaced by manipulation or operation. If the 
cord is injured, the advisability of operative interference will 
depend upon whether the lesion of the cord is transverse and com- 
plete, or whether it is partial. If there are evidences of a trans- 
verse lesion, operation is unavailing and obviously illogical, for 
the cord can not be repaired. It is necessary, therefore, to distin- 
guish between the signs of a transverse lesion nini those of u pur- 



82 



FRACTURES OF THE VERTEUK.1-; 



tial lesion. In a complete transverse lesion tfie history of the 
onset of the symptoms is a sudden one, tlie symptoms appear 
immediately following the fracturing trauma ; whereas, if a partial 
injury is present, an interval will have elapsed before the symp- 
toms develop; the appearance of symptoms is gradual rather 
than sudden. In a complete transverse lesion the motor par- 
alysis is found to be complete, 
and the paralyzed muscles are 
flaccid ; whereas if the lesion is 
a partial one, the motor paralysis 
is limited, some muscles of the 
limbs are paralyzed, others are 
not, and there is often noticed 
muscular spnsm in the afiected 
limbs. In a complete transverse 
lesion sensation is entirely gone ; 
whereas in a partial lesion some 
sensation is felt. The knee- 
jerks are variable in the com- 
plete transverse lesion ; they are 
often absent. In the partial lesion 
they are usually present. In the 
transverse lesion the paralysis of 
the bladder and rectum is com- 
plete ; whereas in the partial 
lesion paralysis of these organs 
is not always present. Priapism, 
sweating, and involuntary mus- 
cular twitchings are seen more 
commonly in case of injury to 
the spine associated with com- 
plete lesions of the cord than 
in cases with partial lesions of the cord. In partial lesions 
variations from the definite types of symptoms are seen. The 
symptoms are more or loss irregular. In total lesions of 
the cord operation can do no good. The cases of pressure 
from fragments of boiie — that is, those occurring for the most 
part in the cervical region, in which the lamina; of the vertebr-E 







rt'inpTcwteJ 1 



TRKATMKNl- 83 

are fractured — demand operation. All other cases of bony 
pressure are those due to dislocation of vertebra; which are 
remediable either by operation or manipulation. In these cases 
the prognosis depends upon the damage done the cord. 

It is the result of experience that in cases of injury to the 
spine severe enough to do damage to the cord usually irreparable 
injury has been done by either a distinct crush of the cord or hemor- 
rhage into the cord. Hemorrhage into the cord takes place often 
extensively and some distance from tlie seat of the chief lesion, 
so that even if the seat of the crush of the cord were reached 
by operation, damaging lesions would still remain unrelieved. 




It is also the result of experience that removal by operation 
of the lamins and spines of the vertebra; in the .'iuspcctcd 
region of fracture very rarely — almo.st never — reveals any reme- 
diable condition or affords any evidence of the (.-xact seat of the 
lesions or their extent. The reason for these facts is that the 
dura at the seat of a crush of the cord, whether partial or c<)m- 
plete, remains intact and untorn, and that extradural hemorrhage 
is unusual. The surgeon, therefore, after removal of the lamina; 
is as much in doubt as he was before. Operation, therefore, 
in complete lesions holds out no hope of benefit. It is 
said that the chances of the symptoms being due to prosure 



84 FRACTL-RES OF THE VERTFIIIRT: 

by extradural blood-clot or bone justify operative interference 
in these apparently hopirl ess cases. This is true in those cases in 
which the lesion of the cord is partial, but never when the lesion 
is completely transverse. 

Operative interference, then, may be summarized somewhat 
as follows : 

In all partial lesions operation is demanded ; in fractures of 
the laminar and spines operation is demanded ; in all lesions of 
the Cauda equina operation is demanded ; in all complete lesions 
operation is contraindicated. 

It is an interesting fact clinically and pathologically that in cords 
compressed at a definite level with destruction of the cord, at the 




seat of compression there is often found a hematomyelia (hemor- 
rha^ into the subsLancc of the cord) several vertebrae above and 
below the fracture, thus showing how extensive is the acting force. 

A stuih' of the drawings made from actual sections of tlie 
spinal cords of cases of fracture of the spine will indicate the 
different I<rsions already mentioned. 

Figure $6 is from a fracture of the cervical vertebra;, showing 
estmction of the cord at the seat of the lesion, with localized 

cssun; from bone and blcxxi. I^w down is seen an extensive 

■radural hemorrhage and a hematom>-eIia some dLstancc from 

! original trauma. 



Figure 87 is from a dislocation and fracture of the fifth upon 
the sixth cervical vertebra. There was complete paralysis below 
the lesion. Trephining was done. The patient lived without 




improvement seventeen days. This section of (he cord is 
taken a little above the lesion and shows clearly a hcmato- 
myelia of the right posterior cornu. 



86 FKACTLiRI^S OF THIC VEKTEBK.M 

Figure S8 is taken from a section of the cord of the preced- 
ing case a little below the lesion, showing complete destruction 
of the gray matter of the cord ; the dura remained intact. 

Figure 8g is also taken from a section of the cord of the pre- 
ceding case, but at the seat of the lesion, showing a destruction 
of the gray and white matter of tlie cord anteriorly next to the 
bodies of the vertebni;. The dura remained intact, there being 
to the operating surgeon no evidence posteriorly of any disturb- 
ance having occurred anteriorly. 




fBi«n|egio nnd iphlncler nar»ly»(«. 
Death tunc nionlhs uflci iccldciil. Dleil 
ofpllthisiB. Typco(cOmpre«i011(r.r- 
liiie (Warren Muacum. ipecimcn «il. 

Figure 90 is a section of the spinal cord of a woman who fell 
from a trapeze to the floor, and fractured and dislocated the 
sixth cervical vertebra. Operation was done. She lived three 
days. A little distance (two segments) from the seat of the lesion, 
where the cord was cru.shed anteriorly, was found a hema- 
tomyelia of the white matter posteriorly. The dura was 
intact. 

These specimens, which illustrate the common lesions of the 
spinal cord following fractures and dislocations of the vertebra. 



TREATMENT 87 

demonstrate the utter futility of operative interference in cases 
of crush of the cord with signs of a complete transverse lesion. 
The Immediate Rectification of the Deformity and immo- 
bilization by the Plaster-of- Paris Jacttet. — With our present 
knowledge of the pathology of these fractures, and excepting 
cases of fracture of the vertebral arch alone and pressure upon 
the Cauda equina and partial lesions of the cord, there can be no 
doubt that the best treatment for fracture of the vertebra; is by 




means of expectant methods. The methods are as follows : 
Immobilization of the part by a plaster-of- Paris jacket applied to 
the trunk, if there is no deformity. If there is deformity, cor- 
rection of it and immobilization of the spine in the corrected 
position. Tlie correction of the deformity must be immediate to 
avoid irremediable softening of the cord from pressure ; and this 
may occur even within forty-eight hours. 

Method of Applying the Plaster-of- I'aris Jacket. — This differs 
in no respect from the usual methods of application, with the 



FRACTURE"! OF 1 



exception that the patient .•ihould be protected from any unusual 
or sudden jar or movement. The trunk having been properly 
protected by a tightly fitting shirt, the patient is carefully placed 
prone in a hammock. The patient may be placed upon two kitchen 
tables, which are gradually pulled apart, allowing the trunk to be 
unsupported between the tables until the desired extension is ob- 
tained. If the tables are used, great care must be exercised that 
proper assistants secure the 
shoulders and hips of the 
patient during the proced- 
ure. Gentle, firm pressure 
is made upon the projecting 
vertebral spines until re- 
duction is complete. The 
jacket, reinforced poste- 
riorly by extra layers of 
bandage, is then applied. 
Death may occur instantly 
during this procedure, but 





if gentle measures are used, the likelihood of such a catastrophe 
will be modified. An anesthetic given to primary anesthesia is 
oficn of service. A sufficient number of assistants should be at 
hand — there should be at least four. 

Itis. of course, impossibletosay what cases will be saved by this 
means, but it has been proved to be a life-saving measure in a few 
cases. The paiicntwill be more comfortable and moreeasily man- 



TKHVI'MENT S9 

aged afier sucli a procedure. The hopelessness of tlie results of 
fractured spine justifies the surgeon in undcrlaking almost any risk. 
Cystitis. — Life may be prolonged, if not saved, by the proper 
Irealiiient of this distressing affection, which is always associated 
with fracture of the spine. In a number of tliese cases death is 
due to a pyelitis and nephritis following a cystitis. These com- 
phcations may be avoided for a definite time if the bladder is 
thoroughly drained by urethral catheter or by perineal drainage. 
The bladder may be kept aseptic by douching regularly with a 




solution of boric acid or permanganate of potash and by the 
internal use of umtropiii. Great care should be e.vcrcised in the 
avoidance of bed-sores ; it is easier to prevent than to cure them. 
Summary of Treatment. — Fracture of the arches of the 
vertebra;, whether open or closed, should be subjected to 
oper.ition. Fracture and compression of the Cauda equina 
after six weeks of waiting for spontaneous recovery should 
be treated by npcratinn. In all [lartial lesions of the cord 



go FRACTURES OF THE VEKTEBR.*: 

operation is demanded. All other fractures showing a complete 
transverse lesion of the cord should be treated expectantly. 

GUNSHOT FRACTURES OF THE VERTEBRAE 

These open fractures arrange themselves into three groups for 
practical purposes. 

First group. Those cases in which the viscera of the thorax 
or abdomen are simultaneously injured. 

Second group. Those cases in which the bullet has entered 
the spinal canal and has injured the spinal cord. 

Third group. Those cases in which the spines and laminae 
or the arches of the vertebr.-e are injured. 

Treatment. — In all cases the external wound should be care- 
fully cleansed and protected by an antiseptic dressing. 

The degree of shock should be observed. Any signs of a 
lesion of the cord should be recorded. Evidence of damage to 
the viscera within the chest or abdomen should be sought for. 

In the absence of great shock it is wise for the surgeon, under 
antiseptic and aseptic conditions, to lay open the wound, to 
thoroughly disinfect it and to attempt to ascertain the condition of 
the cord and vertebra:. If the symptoms point immediately to a 
transverse lesion of the cord extensive operation is contra- 
indicated. 

The character of the dama^^e done bv the bullet to the verte- 
bra: and spinal cord cannot be wholly determined except by 
operation. In operating there is always the possibility of dimin- 
ishing the chances of infection through the bullet wound and of 
relieving pressure upon the spinal cord from blood clot and 
fragments of bone. 

A crushed cord is not incompatible with life. Such a patient 
may live for several months or even for several years. Opera- 
tion may prevent death from sepsis, even if a crush of the cord 
exists. 



CHAPTER IV 

FRACTURES OF THE RIBS 

Anatomy. — Palpation of most of the ribs is comparatively 
easy. The upper seven ribs on each side articulate with the 
sternum. The eighth, ninth, and tenth ribs are connected by the 
costal cartilages anteriorly, but the eleventh and twelfth ribs 
have no anterior attachment. These lowest ribs are, therefore, 
less liable to fracture. The first two ribs are somewhat protected 
by the clavicle from direct violence, although great depression 
of the shoulder may bring the clavicle to bear directly upon the 
first ribs, and this may be a cause of fracture. The ribs are so 
elastic in childhood that fracture then is extremely rare. Direct 
violence is the common cause of fracture. 

Sjrniptoms. — In partial fractures there may be no symptoms. 
Upon forcible expiration (as in sneezing, coughing, laughing, 
crying, or in breathing hard) pain may be felt at the seat of 
fracture. So definite is the pain that the patient may be able to 
place his finger accurately upon the seat of fracture. 

Crepitus is often felt by the patient when moving or making 
an expulsive effort. Crepitus is elicited for the examiner by 
firmly placing the palm of the hand flat upon the chest at the 
supposed seat of fracture when the patient coughs. If crepitus 
is present at the time of coughing, a slight crunch or click will 
be felt and sometimes heard. The stethoscope placed near the 
supposed fracture will often assist in detecting the crepitus. The 
ribs should be palpated systematically, and the chest slightly 
compressed between the two open hands anteroposteriorly and 
laterally to detect crepitus. The natural inclination of the 
ribs should be borne in mind during palpation. Respiration 
will be short and catchy, and accompanied by a characteristic 
grunt. 

The attitude and movements of the patient are very deliberate, 
guarded, stiff, and in severe cases suggest the movements of a 

91 



y2 FKACTLRE.S OF THE RIHS 

cliild witli acute caries of the clor^ai spine. There may be a 
sliffht cough. 

Complications of Fracture of a Rib. — Injury to the pleura 
and lung not uncommonly occurs. lis existence is manifested 
by coLigh, bloody expectoration, and emphysema. Emphysema 
may extend over the whole chest and up over the neck and face 
(see Fig. 98), and even over most of the body. Emphysema 
unassociated with a wound of the superficial soft parts is of little 
importance. Pneumothorax may be present. Injury to the 
heart and pericardium and hemorrhage from an intercostal arterj- 
are unusual. A dry pleurisy, disappearing rapidly, localized at 




: Eiiil>hv«m> followi 



the seat of fracture, is quite commonly detected by the steth- 
oscope. The relations of a rib to the pleura and intercostal 
vessels are important in this connection (see Fig. gg). 

Treatment. — The complications must be attended to accord- 
ing to medical principles. A cough mixture, if necessary, con- 
taining morphin is a great help during the first week. It is diffi- 
cult to reduce a fracture of a rib and to hold it reduced. The 
deformity and loss of function consequent upon the union of a 
fractured rib in malposition is fortunately not very great (see Fig, 



TRKATMENT 



93 



lOo). However, the relief of the patient upon the partial tni- 
mobilization of the fracture is great. By pressure of the hand 
the ribs may be steadied and the fragments brought into excel- 
lent apposition, and by a pad held in place by a swathe of adhe- 
sive plaster this apposition can be maintained. The application 
of an adhesive- plaster swathe is attended with much comfort, and 
is easily accompIi.shed. The .swathe should be broad enough to 
cover the chest six inches on either side of the fracture of the rib, 




tofmot T. Owigtai). 



and long enough to extend three-fourths of the way around the 
body. It is applied as follows ; One end is fixed to the trunk of 
the patient at the spine, the patient standing erect with the hands 
upon the top of the head (see Fig. loi). The surgeon, taking the 
loose end of the swathe and holding it taut, walks around the 
patient, applying the swathe to the patient's chest while the patient 
.standing turns as if on a jiivot toward the surgeon if possible 
(see Fig. 102). It i.s ini[>ortant to avoid covering the constantlj' 
moving abdomen by the swathe. A swathe made of several Umil; 



TREATMENT 95 

Strips of adhesive plaster, each strip being four inches wide, inibri 
cated in the application, will often prove more comfortable than a 
single swathe. The comfort attending the wearing of such a 
swathe speaks much for its efficacy. 

Operative Treatment. — If the fracture is comminuted or if 
there is great displacement that is irreducible by pressure, an 
incision and elevation of the parts and immobilization by suture 
are to be considered. 

After-treatment. — The upright position will give the most 
comfort. The swathe should be changed at least once each 
week. It will require about three weeks for the union to become 
firm. A cotton swathe may be worn during the third and fourth 
weeks in place of the adhesive-plaster swathe. At the end of 
four weeks all swathes may be removed. Massage to the seat 
of fracture will, after the first week, hasten healing and a resto- 
ration of the parts to the normal position. If there have been 
any pleural or lung complications, great precaution should be 
exercised in the after-care. The avoidance of exposure to cold 
and of great bodily exertion for a period of two months or more 
following recovery from the complication is necessary. 

Other injuries, such as strains of the shoulder and back, are 
likely to appear some days after the acute symptoms of a fracture 
of the rib have subsided. It is well to examine the patient with 
a fractured rib for associated injuries. These associated sprains 
often cause considerable anxiety to the patient for fear that more 
serious trouble than a broken rib exists. In patients over fifty 
years old *' neuralgic pain " at the seat of fracture will sometimes 
persist for several weeks after the fracture is firmly united. This 
may be relieved by applications of moist heat to the affected part 
and by counterirritation of a more vigorous kind. The use of 
tincture of iodin and blisters is often a great help. In the aged 
the shock of the injury is considerable. In feeble persons a 
pleurisy or pneumonia may prove fatal. 

Treatment directed to the removal of the emphysema is ordi- 
narily unnecessary. The emphysema usually disappears in a 
week or ten days. If the distention of the subcutaneous tissues 
is extremely painful and increases very rapidly it may be wise to 
make several antiseptic incisions over them, allowing the air to 
escape, to relieve the tension of the skin. 



CHAPTER V 

FRACTURES OF THE STERNUM 

It is difficult to palpate the sternum accurately. The epi- 
sternal notch is felt between the two inner ends of the clavicles. 
The junction between the first and second portions of the sternum 
is distinctly felt opposite the second costal cartilage as a ridge. 
The dififerent sites of fracture are shown in figure 103. The 





Fig. 103. — Sites of fracture of the ster- 
num (after specimens 5149. 9/8, 5>5'. S'.so. 
97''' 977i Warren Museum). 



Fig. 104 — Separation of manubrium 
and gladiolus ; displacement of lower por- 
tion forward ; side view. 



fracture that is usuallv due to direct violence is seated in the 
upper part of the second portion of the sternum, near the junc- 
tion of the first and .second portions. The upper fragment is 
displaced backward behind the upper end of the lower fragment 
(see Fi<;. 104). The displacement, the abnormal mobility, and 

possibly crepitus after each respiratory act or upon coughing, 

96 



:|{ATMENT UK FRACTUKE OF THE STEKSLM 



97 



the localized area of pain, all increased by pressure, help to make 
the diagnosis certain. 

The patient stands in a characteristic fashion with body bent 
forward. It is ainiost impossible to distinguish a dislocation at 
the junction of the first and second portions of the sternum from 
a fracture within the first portion of the sternum. Careful palpa- 
tion alone and consideration for the age of the patient will enable 
one to decide. The ossification of the sternum takes place 
irregularly. At the twenty-fifth year all parts are usually ossi- 
fied. The lesions sometimes associated with fracture of the 
sternum — viz., fracture of the ribs and injur}- to the lungs and 




heart — are usually so severe that the patient does not recover 
from them. If no complicating lesions are present, the outlook 
for recovery is favorable. 

Treatment of Fracture of the Sternum. — Spontaneous reduc- 
tion has occurred in sci-eral instances upon coughing or sneezing. 
If the patient is placed upon his back with his head extended over 
the end of the table and the arms are then raised above the head 
and rotated outward slowly and forcibly, the deformity is some- 
times reduced. The body of the patient, meanwhile, is steadied 
by an assistant. Traction and counterlraction are thus made upon 
the two fragments {see Fig. 105), An adhesive-plaster swathe 
should be placed about Ihc chest high up, and held firmly in 



pui^iiitfU \iy «;tf/»|i«» ;i/:ro«;ei the .nhoiilclcrs. Union takes place in 
Uniu \ht(f' in four wrrk.**. The fracture i.s not sohd for from 
«5ix to f j^ht Wfck**, After reMinj^ on the back in bed for three 
w^f'k«» fhf pafirnf may be allowed to be up occasionally with 
( i^rv to avoid violent exertion. For the greatest precaution a 
Irtylor t?|f rl bark bracf\ with apron and liead-support, should be 
\\^('^\ for two niontlm after the patient is up and about. This 
\nmv h ^hnilar to that UMcd in high dorsal caries of the spine. 

Ofiemllve Treiitment. — Incision and elevation of the de- 
pM*«=i«*cd fraj^inrnl have been done successfully, and arc to be 
eoti«<ltlfrrd in dinicull (asrs after the shock of the original injury 
hfi«^ prt^^^ed rtway. 



CHAPTER VI 

FRACTURES OF THE PELVIS 

The pelvic bones are generally considered inaccessible (see 
Fig. 1 06) ; but with a systematic anatomical examination, especi- 
ally if assisted by digital examination by the rectum and the 
vagina, practically all parts of the pelvic bones may be palpated. 
Movement of the hip will often determine the integrity of the 
acetabulum, which is, of course, most difficult to palpate even 
posteriorly by the rectum. Fractures of the pelvis are occa- 
sioned by great violence. Fracture occurs most often in falls 
from a height, and is due to the sudden pressure upon the pelvis 
through the thighs and hips (see Fig. 107) or through the spinal 
column upon the sacrum and sacro-iliac synchondroses. Antero- 
posterior pressure and lateral compression, as in the car-coupling 
accident, are common causes of fracture. From a clinical stand- 
point these fractures fall into two groups — fractures of the indi- 
vidual bones without injury to viscera, and fractures at different 
points in the pelvic ring usually associated with visceral lesions. 

Fractures of the sacrum, the coccyx, the symphysis pubis, 
and the ischium are extremely rare. 

Examination. — The examination should be systematically 
made in order to cover thoroughly the irregular bones of the 
pelvis. The ilium of each side should be palpated to detect a 
fracture of either crest. Then the two ilia should be crowded 
gently but firmly together in order to determine crepitus due to 
the presence of fracture elsewhere. Then the pubis and ischium 
upon the two sides are to be palpated externally as far as is prac- 
ticable. Finally, a careful rectal and vaginal examination should 
be made of the pelvic bones. The patient should be catheter- 
ized to assist in determining the presence of an injury to the 
urinary tract. 

Fracture of the Ilium (see Fig. 108). — This fracture is not 
unusual. The crest of the ilium is commonly broken. Pain, 

99 



KAcrUKES Ol" 



swelling, crepitus, and abnormal mobility may be present. There 
is comparatively little displacement. Union occurs in from three 
and a haif to four weeks. The patient ordinarily requires but' 




FiK, iifi.— Prutti 



restraint in bed. The outlook is for a good recovery unless 
there is a visceral lesion. Slight deformity may be noticeable 
upon full recovery (see Fig. 109). 




Fracture of the pubic portion of the ring of the pt-lvis is 

the commonust fracture. It is usually associated with other 
fractures or separations of bony surfaces of the pelvis. Injury 
to the urethra is not uncommon in this fracture (see Figs, i lo, 
111). 

Treatment. — A snugly fitting swathf encircling the pelvis 
should be applied to assist in immobilizing the fracture. If the 
fracture is of the ilium alone, the swathe should be applied 
loosely enough to avoid displacing the fragment of the crest in- 
ward, thus causing permanent deformity (see Fig. loc)). The 
patient should, in all cases, except simple fractures of tlie crest 




P 

^^m of the ilium, be placed upon a properly fitting Bradford frame. 

^^H Upon this frame, and in no other way, can the patient be com- 

^^E fortably nursed. The bed-pan can be adjusted with ease and 

^^B without disturbing the fracture. The bed can be most readily 

^^B changed and the patient kept clean and comfortable. If it is 

^^M probable that movements of the hip-joints cause motion at the 

^^H seat of the fracture, the thighs should be li.\cd so as to immobilize 

^^M these joints. If the patient is on a Bradford frame, sufficient 

^^H immobilization is easily accomplished by encircling the thighs 

^^H separately or together and the frame with a towel ^iwathe. 

^^H Extension of the limbs by weight and pulley may be needed iii 




102 FRACTURES OF THE PELVIS 

addition in certain cases to secure immobilization of the fracture. 
Wiring nr suture of the fractured bones may be entertained and 
practised. Wiring is indicated if comminution or displacement 
of fragments is great. 

Visceral Lesions. — Associated with fractures of the pelvis 




lion IWarccn Muieiini 




there may be lesions of important viscera. These visceral lesions 
render fractures of the pelvis of the very greatest seriousness. 
The trauma causing the fracture may at the same time occasion 
a rupture of the kidney. The bladder, urethra, or bowel may 
also be ruptured. The shock" associated with a fracture of the 



RUPTURE OF ' 



103 



pelvis is great. If there is a visceral lesion, the primary and 
secondary sliock will be very great. 

Rupture o( the Urethra. — This is sometimes associated with 
fracture of the pelvis (see Fig. 112). It may be due to the 
original trauma, as a fall or blow on the perineum, or it may be 
caused by bony fragments lacerating the urethra, or by a simple 
separation of the symphysis pubis. Pain at the seat of the lesion, 
pain upon pressure in the perineum, retention of urine, urethral 



hy Prol 




wighl). 



hemorrhage, swelling in the perineum, usually exist. Under these 
circumstances perineal section is indicated in order to drain the 
wounded area and the bladder. If a catheter can be passed to 
the bladder and the local swelling does not increase, permanent 
or interrupted catheterization is indicated. The patient should, 
however, be watched carefully for the signs of extrava.sation of 
urine. If at any time the catheter can not be passed, operation 
should be done at once, as in the first instance. 



I04 FKACTL'kE.S OF THE PELVIS 

Rupture of the Urinary Bladder. — This may be either extra- 
or intraperitoneal. When the bladder is empty, it is low domi 
in the pelvis and can be injured only by a fracture of the peU-is. 
The rupture of the bladder due to fracture of the pelvis is usually 
extraperitoneal and it is situated on its anterior surface. 

(}n account of the fracture the patient can not walk. Rup- 
ture of the bladder itself might occasion inability to walk% 
at least any long distance. There is great hypogastric pain, 
frequent desire to micturate and inability to pass urine. A few 
drops of bloody fluid escape from the meatus. Dullness may 
be present in the lower abdomen and loins. Soon after the 
accident, if not immediately, there is great prostration. Evi- 
dences of shock are seen in the pallor of the face, the anxious 
expression, the feeble pulse, the cold, clammy skin, and feeble 
voice. The abdomen becomes distended, the temperature rises, 
and delirium, coma, and death follow with certainty unless opera- 
tive interference has relieved the condition at a ver>' early 
hour after the accident. The patient dies from shock, hemor- 
rhage, or septic peritonitis. If the patient is seen soon after the 
accident. Ixrfore untoward symptoms have appeared, and has not 
micturated for some little time, he should be catheterized. An 
empty bladder will be found or a small amount of bloody fluid 
will be withdrawn, which rather confirms the other evidences of 
ruptured bladder. If there is doubt as to the rupture of the 
bladder, the symptoms should be watched. The symptoms of 
rupture may be masked or delayed by the associated lesions. 
The urine may be tinged with blood because of a contusion of 
the bladder. The catheter may be passed through the bladder- 
wall, and be felt to enter the abdominal cavity, evacuating bloody 
fluid. All fluid having been removed from the bladder, if a 
measured amount of sterile water is injected into it, and all 
that was injected does not return, presumption of rupture of the 
bladder is very great. Under such circumstances the dull area 
in the groins and lower abdomen of extraperitoneal rupture 
will be increased. 

Exploratory laparotomy should be done, and if the extra- 
vasation proves to be extraperitoneal, drainage of this area is 
demanded. Temporary drainage of the bladder, either urethral 



PROGNOSIS 105 

• 

or through perineal section, will be needed to .permit healing 
of the bladder wound. The bladder wound is usually inacces- 
sible to suture in these cases. 

Prognosis. — A guarded prognosis should always be given in 
any case of fracture of the pelvis. Fractures of the iliac crest 
ordinarily recover in a few weeks. In fractures complicated by 
rupture of the bladder or bowel the prognosis is extremely 
grave. 



CHAITKR VII 

FRACTURES OF THE CLAVICXE 

Anatomy. — The clavicle is subcutaneous tliroitghout its 
wliolc length (sec Tig. j 14). The acromioclavicular joint is at 
its outer end. The sternoclavicular joint is at its inner end. 
The clavicle lies in a muscular plane made up of the trapezius 




.is^ks.,b„ve .mdtliL 
.1csIk1o« (see i I- I 
ii>n .iml the dirtctini 



leltoid.pectoralis 
14I It is inipor- 
(il ilic acromio- 



SYMPTOMS 



107 



clavicular joint in order to discriminate between a fracture of the 
outer end of the clavicle and one of the acromial process. It is 
likewise important intelligently to palpate the normal shoulder, to 
determine that the acromial process does not form the outer limit 
of the shoulder, but that it is formed by the greater tuberosity of 
the humerus. 

Symptoms. — The common seat of fracture is in the middle 
third of the bone (see Figs. 1 15-1 18 inclusive). The shoulder, 
having lost the support of the clavicle, falls forward and drops 
inward, consequently the outer fragment that moves with the 
shoulder drops below the inner fragment and overlaps it in 
front. The inner fragment, having attached to it the sternocleido- 




Fig. 115. — Fraclure at ihe inner and 
middle thirds of ri^ht clavicle from above 
(Warren Museum, specimen 1214). 




FIr. 116. — Fracture toward middle of 
clavicle, a liitle to the inside (common 
site). Right clavicle from above (Warren 
Museum, specimen 9S7). 




Fig. 117. — Fraclure at the outer and 
middle thirds of left clavicle from above 
(Warren Museum, specimen 9H7). 




Fig. 118.— Fracture at the outer end of 
clavicle. Left clavicle from above (War- 
ren Museum, specimen 7900). 



mastoid muscle and being comparatively free to move, is drawn 
slightly upward. The attitude of the patient is characteristic 
(see Figs. 1 19, 120) : he stands with the head inclined to the in- 
jured side, thus relaxing the pull of the sternocleidomastoid muscle 
upon the inner fragment. The shoulder upon the .^de fractured 
is depres.sed ; the elbow and forearm upon this same side are sup- 
ported by the well hand. This is the attitude of greatest com- 
fort. The shoulder — /. t\, the space between the base of the 
neck and the greater tuberosity of the humeru.s — is shortened 
upon the injured side (see Fig. 131). If the fracture lies within 
the limit of the coracoclavicular ligament or outside of it, there 
will be no appreciable displacement (see P^ig. 121). The diagno.^i.s 



TREATMENT IN ADULTS I O9 

under these circumstances will be difficult. Localized pain and 
the disability of the arm will suggest the lesion present. 

Fracture of the Clavicle in Childhood. — More than one-third 
of all fractures of the clavicle occur in children under five years 
of age. A trivial injury is the usual cause of the fracture. A 
little child may fall from a low chair or out of bed and fracture 
the bone. The fracture is most always incomplete or green- 
stick. 

The child cries upon moving the arm. Lifting the child 
by placing the hands in the armpits causes pain. The arm of 
the injured side may be used as naturally as the other or there 
may be some disability, perhaps simply a disinclination to use 
the arm. If the fracture is greenstick, a tender swelling 
appears at the seat of the fracture. If the fracture is complete, 
an unevenness will be felt at the seat of fracture according to the 
amount of displacement. The displacement is usually slight in 
childhood. The characteristic attitude seen in adults (see Figs. 
119, 120) is much less marked in children, and if the fracture 
is greenstick, there is no tilting of the head and depression of the 
shoulder. If the child, as so often occurs, persistently holds the 
head so that a careful examination is impossible, then it is best 
to place the child on its back, and while its legs and arms are held 
firmly, the head and shoulder may be gently and gradually sepa- 
rated. The examination can then be completed. 

Treatment in Adults. — The displacement should be corrected 
and the corrected position maintained (see Figs. 122, 123). The 
indications are to carry the shoulder, and with it the outer frag- 
ment, upward, outward, and backward. 

The Recumbent Treatment. — The displacement is most satis- 
factorily corrected by the patient lying recumbent upon a firm 
mattress. The weight of the shoulder in this position does not 
impede reduction, as in the upright position, but assists it. A 
firm and small pillow should be placed between the shoulders. 
The shoulders fall backward of their own weight over the pillow 
carrying the outer fragment backward at the same time. Pad- 
ding of the fragments of the clavicle, the application of pressure- 
to the elbow, may be more satisfactorily accomplished in the 
recumbent than in the upright position. Union ordinarily occurs 



112 FRACTURES OF THE CLAVICLE 

within three weeks. At the time of union or shortly after the 
patient may be allowed up with a simple retentive dressing, a 
slinj^, and a swathe. The bed treatment is hard to enforce because 
the fracture is the cause of so little real permanent disability. 
If there is much displacement and deformity can not be corrected 
and held properly, the bed treatment is indicated. In the 
simultaneous fracture of both clavicles the recumbent bed 
treatment is the best (see Operative Treatment of Fracture of 
the Clavicle). 

The Modified Sayre Dressing. — The shoulder and arm are 
unwieldy in adults. It is, therefore, necessary in treating a frac- 
ture of the clavicle by an ambulator)' method to secure a very 
firm hold upon the shoulder in order to maintain the clavicular 
fragments in a good position. 

The modified Sayre adhesive-plaster dressing is the best. It 
is applied as follows : Provide three strips of adhesive plaster, 
four inches wide, and long enough to extend once and a half 
around the body. The skin surfaces that are to come in con- 
tact — namely, the a.xilla and chest and forearm — are separated 
by compress cloth and powder. A dressing towel, folded like 
a cravat, is snugly pinned high up about the upper arm (see 
Fig. 1 24). This towel may be held neatly by a strip of adhe- 
sive plaster. One end of the first adhesive strap is fastened 
loosely about the towel-protected arm with a safety-pin. While 
an assistant holds the shoulder well back the arm is carried back- 
ward, and held by the fastening of the first adhesive strap about 
the body (see iMg. 125). This affords a fixed point at the middle 
of the upper arm. The second strap, with a hole in it to receive 
the point of the elbow, is started upon the posterior surface of 
the injured shoulder (see iMg. 126) and carried under the elbow 
of the injured side and over the well shoulder (see Fig. 1 27). 
The forearm is flexed, and rests upon the chest. In applying 
this second strap the shoulder is raised and the elbow is carried 
forward, thus forcin;^ the shoulder slightly upward and backward 
of the fixed point used as a fulcrum (see 1^'ig. 128). A third strap 
may be placed around the trunk and arm to steady all in good 
position. ( )\ er this dressing may be put a X'elpeau bandage 
for the comfort of the support which it affords (see Fig. 129). 



lUliAIMKM' IN CHILDKEN II3 

The adhesive plaster may be covered with bits of gauze bandage, 
111 part to protect the skin from imdue chafing, sufficient plaster 
surface remaining uncovered to prevent the straps from slipping. 
Occasionally, pads (see Fig. 130) upon the clavicle may be used 
to correct the deformity, but the bone is so subcutaneous liiat 
the skin can not bear great pressure without damage. If pads 
are used, they must receive frequent inspection. 




Treatment in Children. — The skin of the child must be pro- 
tected by powder and careful dryini; before the arm is done up. 
if it is a grecnstick fracture and there is slight deformity, this 
deformity should be corrected by pressure with the thumbs. An 
anesthetic should be used, After tlic deformity is corrected and 
in cases without deforniil\' it is necessary simply to restrain the 
movements of the arm for two weeks. This is best accomplished 
by a cotton swathe about the boily and upjuT arm, held by straps 



114 



FRACTURES OF THE CLAVI 



nvcr the shoulders and by a cravat sliiij;. In wjirm weather and 
also ill cool weather, for that matter, the arm is to be inspected 
frequently, as often as every third day, when all tlie dressings 
arc removed, the parts bathed with soap and warm water, pow- 
dered, and the simple retentive dressing reapplied. With this 
care only can chafing be avoided. If it is a complete fracture, 
the modified Sayre adhtsive-plaster dressirf; should be used as in 




Isdults. The skin is to be carefully protected, and the dressing 
" most assidttously u-atcbcd. It requires but forty-eight hours for 
t chafing to occur with the resulting discomfort .ind the slow 
pealing which often results. If union is firm after two weeks or 
o weeks and a half, the plaster dressing should be removed and 
i shoulder put up in a simple retentive swathe and slii^, M 
" fitst, inside the clothes; aHcr three weeks, outside the clothes. 



Il6 FRACTURES OF THE CLAVICLE 

In very active children the sling should not be removed until four 
weeks have elapsed. Massage should be given to the forearm, 
elbow, and shoulder after the first week, together with passive 
motion of the elbow. In both children and adults the adhesive- 
plaster dressing should be reapplied at least once every ten or 
twelve days. If the dressing chafes or slips, it may need more 
frequent renewal. 

Prognosis. — Useful arms and shoulders usually result after 
fracture of the clavicle. Almost all complete fractures of the 
clavicle with displacement of fragments, after repair has taken 
place, show unmistakable evidences of deformity at the seat of 
fracture, of shortening of the width of the shoulders, and in 
many instances in children of a slight lateral deformity of the 
spinal column (see F'igs. 131, 132). Fractures within the coraco- 
clavicular ligament having little displacement of fragments show- 
no resulting deformity. Very great deformity does not preclude 
a useful arm. An ununited fracture of the clavicle is unusual ; 
it may exist and cause no especial inconvenience ; it may be 
unknown to the patient. An ununited fracture of the clavicle 
with considerable callus-formation may simulate malignant dis- 
ease of the bone. Laboring men are rarely kept from their 
work more than two months. TVactures of the clavicle in 
young children, if carefully treated, should unite with practically 
no deformity or disability. Greenstick or incomplete fractures 
ma\' show a general bowing of the whole bone, which it has 
been impossible to correct. 

Operative Treatment. — In recent fractures : If there is great 
displacement which can not be held reduced, if sharp fragments 
threaten vessels or nerves, if there is pressure upon either nerves 
or blood-vessels, if the fracture is a comminuted one, and if the 
bone is fractured in two or more places (multiple fractures), it is 
wise to consider of)erativc measures. The fragments can be 
exposed, replaced, and held in position by suturing. Good 
results follow this treatment. After operation for fracture of the 
clavicle a simple retentive dressing of a swathe and cravat sling 
will be needed. It should be worn for at least three weeks. 

In Ununited h'ractures. — If the cause of delavcd union of the 
fracture is a niis})lacecl l)on\' frai^nient, an interposed strip of fascia 



OPERATIVE TREATMENT 11/ 

or periosteum, or an interposed subclavius muscle, operative 
interference may be undertaken with a reasonable expectation of 
securing a good result. If, on the other hand, nonunion has 
existed for a long period (a year or more), it is highly probable 
that the ends of the fragments will be so attenuated that refresh- 
ing these ends for suture would shorten the fragments to such 
an extent that suture would be impracticable. 



CHAPTER VIII 
FRACTURES OF THE SCAPULA 

The spine and acromial process, the coracoid process, and the 
vertebral and axillary borders of the scapula can be palpated with 
comparative accuracy. Fracture ot the scapula is of rather 
unusual occurrence, and always follows great violence (see Fig. 

133). 
Fracture of the body of the scapula is transverse between 

the axillary and vertebral borders or comminuted in various 

directions (see Figs. 134, 135). 

Crepitus, abnormal mobility, local swelling, and tenderness are 

present. Pain is felt upon attempting to abduct the arm. It 

may be impossible to raise the arm to the head. 

Fracture of the Acromial Process of the Scapula. — The 

epiphysis of the acromion unites with the scapula about the twen- 
tieth year. If there is a fracture present, and not a separation 
of the epiphysis, which sometimes occurs, the line of fracture is 
ordinarily outside the acromioclavicular joint. A fracture may 
occur through the acromion nearer to the spine of the scapula. 

Localized pain, swelling, and tenderness, and a flattening of 
the shoulder are present. Crepitus may at times be felt. If the 
fracture is inside the acromioclavicular joint, the flattening of the 
shoulder will be considerable. The head of the humerus is felt 
in the glenoid cavity, thus ruling out a dislocation. 

Fracture of the neck of the scapula is most unusual. If 
present, it may be mistaken for a dislocation of the humeral 
head. 

The acromial process is prominent. The upper arm is length- 
ened. On lifting the arm forcibly upward with the elbow flexed, 
the deformity is corrected, and crepitus is detected. The de- 
formity recurs if this upward pressure is removed. The reap- 
pearance of the deformity and the crepitus serve to distinguish 

118 



TREATMENT OF FRACTURES OF THE SCAPULA 



119 



ihis injury Trom a dislocated shoulder. In a thin pLTSon palpa- 
tion of the edges of the glenoid cavity itself will prove rather 
satisfactory; the crepitus and abnormal mobility can thus be 
more accurately located. 

Treatment in General. — Immobilization of the whole upjKrr 




extremity, except the forearm and hand, is necessary. Localized 
pressure may assist in retaining fragments in place. 

If there is fracture of the body of the scapula, the forearm 
should be flexed to a right angle and held in a sling. The 

skin-surfaces coming in contact should be protected by powder 




I20 FRACTURES OF THE SCAPULA 

and compress cloth. A swathe of cotton cloth should be fas- 
tened about the upper arm and trunk. If the cloth swathe is not 
sufficient to hold the scapula steady, a swathe of adhesive 
plaster should be used, broad enough to extend from the acro- 
mion to the elbow. 

Fracture of the Acromial Process : The skin -surfaces must 
first be protected from chafing. The forearm being flexed, pres- 
sure upward should be made upon the elbow, so as to lift the 
arm and relax the pull on the small acromial fragment. At the 
same time counterpressure is made upon the inner fragment and 
incidentally upon the inner shoulder (see Fig. 130). This pres- 
sure and counterpressure will hold the part reduced. The 
bandage must be inspected frequently each day, in order to 
detect and to relieve too great pressure upon the elbow and bony 
parts of the shoulder. 

Union will take place in from three to four weeks. It is ex- 
tremely difficult to maintain the reduction of the fragment of the 
acromion by any apparatus. The one previously suggested 
meets the indications better than any other. Massage will 
materially assist in hastening the absorption of blood and will 
relieve pain. No very great functional disability results if union 
occurs with bony displacement. 

/ 



CHAPTKk IX 

FRACTURES OF THE HUMERUS 

FRACTURES OF THE UPPER END OF THE HUMERUS 

Anatomy. — The clavicle may be felt tiiroiifjlioiit its entire 

length from sternum to acromion. The acromial process of the 

scapula articulates with the outer end of the clavicle. Tills 

acromioclavicular joint has an anteroposterior direction, and] if 

the line of tlii.s joint is continued anteriorly, it will piiss down 




the front of the upper arm (see I-'ig. 136), The outer odj.;e nf 
the acromion is continuous downward and backward with the 
spine of the scapula. The great titberosily of the humerus 
projects beyond the acromial process, and is covered b\' the 
deltoid muscle. The point of the shoulder its.-lf is made b\' the 
hnmerns and not by the acromion (see l-'igs. 136, 1 3<S). 



122 FRACTURES OF THE HUMERUS 

EzaminatioQ of the Shoulder. — The uninjured shoulder 
should be examined before the injured shoulder. In injuries 
doubtful in character, associated with much swelling of the 
shoulder, and which are painful upon gentle manipulation, the 
examination should be made with the aid of an anesthetic. 



^^^tA 




Glenoid (o>M. 



Fig. 1 37-— Trim 



Coracuid ptoctss. Cli 




(ircat swelling suggests great trauma ; absence of all swelling 
appreciable to the eye suggests slight trauma. 

I-'or the oxaniination the patient should be seated upon a 
rather high stool, so that the shoulder comes to an easy level for 
manipulation. The shoulder should be grasped, so that the head 
of the humerus can be felt between the fingers and thumb of 



one hand pressed under the spinous and acroiniiil processes. 
The other hand should grasp the flexed elbow firmly, in order 
to make the necessary- movements at the shoulder-joint (see 
Fig. 1 39). If the head of the humerus is intact and in its normal 
place, it will be felt to move with the shaft of the humerus, as 
upon the uninjured side. Ail the normal movements of tht- 
shoulder-joint should be made passively and actively — namely, 
the movements of abduction, adduction, forward and backward 




swing, and rotation (see Figs. 140, 141, (42). Those move- 
ments which are painful and limited .should be carefully noted. 
Unless the normal individual standard of movement is known, as 
determined by examination of tlie well shoulder, there can be no 
dellnile interpretation of the conditions e.sisling in the injured 
.shoulder. The condition of the circulation and the presence of 
[Mresis or [wralysis in the limb should be observed. The shaft 



EXAMINATION- OF THE SIIOL'I.DEK I25 

of the humerus should be measured : the measuremt'nt best taken 
is the distance between tlie edge of the acromial process and the 
external condyle of the humerus. The patient should be seated 
with the elbow at the side if possible, and flexed to a right angle 
(see Fig. 143). The forearm should rest on the thigh of the 
same side. The direction of the long axi."! of the humerus 
should be carefully noted. 

The coracoii.1 jirticc^s of ihf scapula in all injuries to the .shoul- 




der should be palpated, for a knowledge of its position assists in 
locating the head of the humerus intelligcnlly {sec Fig. 144). Tlic 
examiner should stand in front of the patient, and place the left 
hand upon the right shoulder and the right hand upon the left 
shoulder, the hands being open. The thumj) should fall below 
the clavicle a full finger's-breadth, when the end of ihc thumb will 
touch the citracoid. It is generally possible to feci the coracoid 
even in vcr\- sujut people and when nuicli swcllin;^ is presenl. 



126 



■L^KES OF THE HUMERUS 



Diagnosis. — It is sometimes impossible to delermiiie Ihe exact 
lesion following an injury to the slioulder. Anesthesia anil the 
Rontgen ray are invaluable aids to diagnosis. It is of the first 
importance to know whether the head of the humerus is in the 
glenoid cavity or whether it is dislocated ; this is determined by 
palpation and by noting the direction of the long axis of the 
humerus. It is next in importance to learn whether there is a 
fracture of the liumerus. If the liiinicral htad rotates with the 







shaft, there is probably no fracture unless there is one with impac- 
tion. If the humeral head does not rotate with the shaft, then 
there is a fracture. If crepitus is present, the diagnosis is con- 
firmed. After inj ury to the slioulder the following fracture lesions 
may be present, and are to be considered : 



Fracture of the ar 
Se|>aration of the 
Fracture of the si: 



itumical neck of the humerus. 
ipl'tT humeral eiitphysis. 
■L'ical neck of the hiimeriis, 



I 



I 



DIFFERENTIAL DIAGKOSIS 137 

In any one of lliese instances a dislocation of the humeral 
head from the glenoid cavitv may exist and complicate the case. 

Simple Dislocation of the Humeral Head, Subcoracoid (see 
Fig. 145). — The attitude is characteristic; the affected arm 
is held flexed, with the elbow away from the side and the arm 
rotated inward. The anterior axillary fold is lowered upon the 
injured side. The long axis of the shaft of the humerus is 




inclined inward. The roundness of the shoulder is flattened. 
The acromial process is prominent. The head of the humerus 
is out of the glenoid cavity, and most often lies under the cor- 
acnid process. The elbow can nut be brought in front toward the 
median line, nor can the hand of the injured arm be placed upon 
the opposite shoulder. Active and passive movements at the 
shoulder-joint are greatly restricted. Measuring from the acro- 
mial process to the external epicondyle of the humerus, the 



I2S 



FRACTLTKES OF THE HUMERUS 



upper arm, in a siibcoracoid dislocation, is lengtliened. A soft 
crepitation may be detectt-ti in manipulating the shoulder, which 
simulates bony crepitus. 

Fracture of the Anatomical Neck (see Figs. 146, [47, 148. 
149. 150, 151). — This is rare. It occurs in elderly people. 
Swelling of the shoulder is evident. Anesthesia is necessarj- 
for a careful examination with deep palpation. There is thick- 
ening of the neck of the bone. Crepitus will be felt unless the 
fracture is impacted. There will be pain upon movirsj the shoul- 




der. Abnormal mobility may be felt high up the shaft close to 
the head of the bone. This fracture lies wholly within the cap- 
.sulc of the joint. 

Separation of the Upper Epiphysis (sec Figs. 153, 153, 154, 
•55. '5*''t- — T^'"^ separation of tiie upper humeral epiphysis will 
not neces.sarilj- open the joint cavity, for the capsular ligament is 
firmly attached to the epiphysis and the synovial membrane is but 
loosely attached li> the diaphysis. The line of the separation of 
the upper epiphysis of the humerus begins on the inner side of 



[JirPKKKMIAL DIAGNOSIS 1^9 

tlie liead of the bone and tuus across almost lioriKontally, rising 
toward tlie center of the shaft, and ends in the outer side of the 
bone, so that the epipliysis includes the tuberosities. 

This happens to young people, but never after the twentieth 
year. The most frequent period is between the ages of nine and 
seventeen years. Ordinarily, the upper end of ihe lower frag- 
ment projects forward and inward, producing a characteristic 




deformity. The head of t!ie bone is in the glenoid fossa, but 
rotated by the muscles attached to it so that its articular surfdce 
looks downward. It does not rotate with the shaft. The crepi- 
tus is of a softer quality than in cases of fracture — /.<■., carti- 
laginous. Localized piiiu and swelling are present. A puckering 
of the skin, caused by the hooking of the lower fragment into 
the skin, is characteristic (see Kig, i 53). Palpation reveals the 
upper end of ilic siiaft. A high lesion near the joint in a young 



I 




Fig. 151.— Normal •houldi^r, sliowiiu- epiphysis o( upper eii.l of humrtus ( X-rf 




Iwlu* uiiim»l plairfot 

tiiif >n>tii, Sunn 11K' ai df 



Clavicle. Scapula. 




Fin;. 156.— Fracture of hi|fh surfcical neck, or seuaralioii of epiplnsis with rolalion t»f head 

(X-ray tracing of figure 15.^;. 



/I 
/ 1 
I I 
I \ 

I I 

I ' 



\ 



"V — ^~ — KpipliysiN. 









\ 
\ 

I 



I.owei fraKincn: 
and callus. 



^'K- IS7. — OI<! fraclun- of surgiial neck liiRh up, siniulatin>; inu* epiphyseal stpai.if ini 

(X-ray traciiiK>' 







It" (.'"flwct ""Bme'm''i"wa?d?'^ld"h^rtire unreduf^Yx-'raf 




MuM.'um. ipcciKivii 3s.t9i 




Fig. i6j.— Diaitram showiiie 
UHulllliplu«neii( ill (radure o7 








13^ 



FRACTLRES OF THK HUMERUS 



patient, showing displacement forward and inward of the shaft, 
is very suggestive of epiphyseal separation. 

Fracture of the Surgical Neck (see Figs. 1 59, 160, 161, 162, 

163, 164). — Any fracture below the epiphyseal line of the upper 
end of the humerus and well within the upper fourth of the 
shaft of the bone may, for all practical purposes, be regarded 
as a fracture of the surgical neck of the humerus. Fracture of 
the surgical neck is the common fracture of the upper end of 
the humerus. Fracture of the anatomical neck is most often 
seen in the aged. Separation of the upper humeral epiphysis 
occurs in youth. 



\ 



/ 



A 

' I 
I 
I 



/^ 




\ 



\ 



\ 
Upper fragment. 



1 Lower fragment. 



I 



Fig. 164.— Fracture of surjjical tierk of Ibe hunifnis. Same as figure 163 after red urt Ion 
hv open incision and wiring with silver wire, kecovery as to motion conif))ete (X-ray 
tracing) (Kliot). 



The head of the bone is found in the glenoid cavity. Passive 
movements are associated with pain, and elicit crepitus and 
abnormal mobility at the seat of fracture, provided, of course. 
the fracture is not impacted. The arm is slightly shortened. 
The arm is held flexed, with the elbow at the side. 

If after an injury to the shoulder no positive evidences of frac- 
ture or dislocation exist, and there is tenderness and localized 
swcllin«4 about the joint, and motion is painful, it is probable that 
simply a contusion exists. 



FRACTURES OF THE UPPER END OF THE HUMERUS I 37 

Treatment. — Fracture of the Anatomical and the Surgical 
Neck and Separation of the Upper Humeral Epiphysis. — The 

importance of these lesions demands, as has been said, an exami- 
nation with the aid of an anesthetic. It is even much more im- 
portant, however, that the first retentive dressing be appHcd witli 
the assistance of an anesthetic. Traction, countertraction, and 
manipulation will secure coaptation of the fra^^mcnts. To hold 
these fragments securely is difficult. To hold a separation of 
the upper epiphysis in position may be impossible without 
operative assistance. To hold any one of these fractures without 
operative interference may be impossible. 

The following is the best and simplest method of treatment : 
The upper arm, shoulder, and trunk should be thoroughly 
powdered. The hand, forearm, and elbow should be bandaged 
evenly, smoothly, and firmly with a bandage of flannel — not cut 
on the bias. A V-shaped pad (with the apex of the V in the 
axilla) constructed of sheet wadding with cardboard outside and 
covered with cotton cloth, should be placed in the axilla of the 
injured side (see Fig. 165). This pad is firm, and fitted to the 
trunk in order to support the inner side of the upper arm 
(see Fig. 166). If thought wise, a thin coaptation splint may be 
placed between this pad and the inner side of the upper arm 
for more direct support. The forearm is held flexed. The 
shoulder is now well padded with one layer of sheet wadding. A 
plaster-of-Parisshaulder-cap is applied so as to cover the whole 
shoulder, the anterior and posterior aspects of the chest, and the 
outer side of the upper arm down to the external condyle of the 
humerus (.see Fig. 167). This shoalder-cap is made of washed 
crinoline, six layers thick, into which has been rubbed plaster-of- 
Paris cream. Its exact shape and extent are seen in the plates. 
A gauze bandage encircling the trunk, arms, and shoulders should 
be used, in order to hold the upper arm at the side and closely 
applied to the coaptation splint and the axillary pad, and in order 
to secure the shoulder-pad firmly in place. Often better than the 
plain gauze bandage is a roller bandage of unwashed crinoline, 
which is applied just after dipping it in lukewarm water (see Fig. 
168). The starch of the crinoline bandage after being wet, 
stiffens the crinoline as it dries and makes a particularly firm and 



I'RACTURES UF THE UPPER END OK ' 



"39 



efficient dressing. A towel folded thin or a piece of compress 
cloth should be placed against the trunk upon the well side. 
Against this the circular turns of the bandage rest, thu.s causing 
less discomfort to the patient than if ihey bear directly upon 
the chest. The forearm is supported by a cravat sling (see Fig. 
167). By this method of immobilization no active traction is 
exerted upon the lower fragment. The weight of the arm, being 
unsupported at the elbow, exerts slight traction. 




iltncy pad unit ilioulilcf-Cni) in poaltion. 
iflkaticn of circulvr bniitlHin to Irutik 
'-■ W^r- SHn«t.«.ho*n. 



On account of the absence of active traction, ambulatory ap[>a- 
ratus can not hold a fracture of the shoulder properly if there is 
much displacement ; particularly if the fracture is oblique. Am- 
bulatorj' apparatus can modify muscular action, insure quiet and 
rest to the part, and. except in the instances just noted, approxi- 
mately maintain the position secured by manipulation and traction 
and countertraction. On account of its limitations, therefore, it is 
important that apparatus should be removed at regular and fre- 
quent intervals and that the whole shoulder should be examined 



I40 FRACTURES OF THK HUMERUS 

in Older to determine errors in position and, if possible, to cor- 
rect them. 

After-care of a Fracture of the Shoulder. — Ordinarily, the 
great swelling associated with this injury disappears in two 
weeks. As the swelling subsides, the normal contour of the 
shoulder becomes apparent again. It is necessar)', therefore, to 
alter the shoulder splint and to apply a fresh one. When the 
patient wearing a shoulder-cap lies down, there is a tendency for 
the shoulder-cap to ride up and away from the shoulder. This 
can be guarded against by carrying the retaining bandage under 
the firm axillary pad and well over the shoulder. Pressure 
points should be carefully watched, and the pressure removed. 
In the course of the treatment of a single case this change of 
dressing will have to be made two or three times. Union will 
be firm in from three to four weeks. As soon as union is firm, 
all splints may be omitted. The forearm should then be held 
by a sling supporting the wrist. At night it will be wise to 
apply a single swathe the first week after the apparatus is left 
off in order to avoid undue motion at the shoulder during sleep. 
In these injuries about the shoulder-joint passive motion should 
be made rather early. At the end of two weeks or two weeks 
and a half repair will have proceeded far enough to allow of the 
gentlest movement at the shoulder without causing any displace- 
ment of fragments. The sooner these gentle movements can be 
resumed at regular and short intervals, the more rapidly the 
shoulder will improve. The common occurrence of a periarthritis 
after an injury to the shoulder emphasizes the necessity of mas- 
sage. It should- be begun as early as the second or third 
week. 

Prognosis and Result. — In young subjects a useful arm will 
result (see Fig. 169). At first, if there is great diflficulty in main- 
taining the reduction of the fragments, the surgeon will expect a 
poor result, but if he persists in efforts at retention and uses 
passive motion early, gradually the movements of the arm will 
return and to a surprising degree. In people past middle life 
there usually is a little shortening of the upper arm and impair- 
ment in some few of the movements of the shoulder, as in abduc- 
tion and external rotation. In individuals over fifty years old, 



FRACTURES OF THE UPPER END OF THE HUMERUS 



141 



excepting those with rheumatism, a useful but not a strong 
shoulder results (see Fig. 170). 

The Prognosis in Separations of the Epiphysis : Bony union 




Fig. 169.— Yoiifijj adult. Fiacturcof the surgical neck of Ihc humerus (X-ra> tracinx, four 
years after ihe accident). Abduction and rotation very slightly lin)itr<l. I'seful arm. 



\ 




X Head of 

\ h»inuM»is. 



Shaft of 



humerus. 



F'g. 170.— Fraclure. Man fifty-five years of age. High surgical neck of humerus. At tht* 
end of five years recover)' with very slight limitation of motion in all directions. Ahducti(»n 
is limited nearly one-half. I'seful shoiilder (X-ray tracing. Massachusetts General Hospital . 
1021 ). 

is to be expected. If there is little or no displacement of frag- 
ments, complete restoration of function will result. If there is 
some deformity remaining after consolidation of the injury, 



142 FRACTURES OF THE HUMERUS 

the usefulness of the shoulder is ultimately and usually restored. 
The deformity becomes less ap{>arent as the sharp bony comers 
are smoothed off by the new ly forming callus. It is not to be 
forgotten in considering the prognosis after all shoulder injunes 
that much of the persisting disability may result from too pro- 
longed immobilization of the arm, even though bony displace* 
ment may not have been ver}* great. The growth of the shaft 
of the humerus in length proceeds largely from the upper epiphy- 
sis. It has been thought by many that an arrest of growth 
of the humerus will follow sejjaration of this upper epiphysis. It 
has been reported to have occurred in eight cases but in no others. 
In several of these cases the injury- to the shoulder was thought 
at the time to have been a simple contusion or sprain. A loss of 
growth is not likely to occur, but may follow injury- to the upper 
humeral epiphysis. 

OMkiue Fracture of the Surreal Neck with Great Dis- 
placement. — This fracture can sometimes be held by placing 
the patient in bed upon the back and making direct traction to 
the upper arm and countertraction upon the shoulder by weight 
and pulley. If the fracture can not be easily held reduced, it 
will be wise to make the closed fracture an open one and to unite 
the two fragments by suture i see Figs. 163. 164). 

Fracture of the Shoulder, Surgical or Anatomical Neck of 
the Humerus, or Separation of the Upper Epiphysis of the 
Humerus, Tof^ether with a Dislocation of the Upper Fragment. 
— The head of the humerus is found in an unnatural posi- 
tion and it fails to move when the arm is rotated. This is 
irenerallv thouj^ht to be an unusual accident, but bv careful ex- 
am- nation manv of these cases mav be detected. During the 
dcrcrnpt at reduction of a dislocated shoulder, fracture of the 
hurnrra! -haft is liable to occur. Amoni^]: manv cases o( frac- 
ture -.n" tiie surL^ical neck the fracture occurred hftv-niiie times 
•vhi'.c: a:i .itt.mprat red jcti-.^n of a dislocation of the shoulder was 

/"-. r*'.; ;.* — ' 'o . : 'us'v. attempts at reoluction by manipula- 

: •: :: :".: . .. -.. i \ ly w^V. nie^jt '.vith raihvire. An attempt should 

:' ■ i" - '■ : t: L :-^ : • r-'-i.ce tii-e '.:i<l-:vat:on by abouction 3.nd trac- 

:: .'. • - :': : . - .r ir::: \:\ .: or-.'--Li''c 'Mtli tiic i'and uDon the 



FRACTURES OF THE UPPER END OF THE HUMERUS 1 43 

loose head in the axilla. It may be possible to reduce the dis- 
location in this manner. If this method fails, an attempt should 
be made to reduce the dislocated head by open incision (arthrot- 
omy) and manipulation of the upper fragment assisted by the 
McBurney- Porter hook manceuver. If this attempt is successful, 
the shaft should be sutured, with an absorbable suture or fine 
silver wire, to the reduced head, and the shoulder treated as if a 
closed fracture existed. 

If it is impossible to reduce the dislocated head or if the head 
is much comminuted, it will be necessary to excise it. 

If operative interference has been decided upon, it is best to 
defer the operation until the acute symptoms have subsided and 
the damaged tissues have recovered themselves. It is the result 
of experience that operation through acutely damaged tissues is 
unwise. The vitality of the tissues is lessened by trauma, hence 
the resistance to infection is temporarily impaired. 

If the reduced head of the humerus becomes necrosed and 
abscesses form about the joint, an unusual occurrence, the head 
of the bone should be immediately excised. 

The After-treatment of Operated Cases. — If reduction and 
suturing have been accomplished, passive motion should not be 
attempted until the repair at the seat of fracture is well under 
way. This will be about the second week. Then gentle move- 
ment may be made and gradually increased. 

If resection has been performed, passive motion should be 
gently begun almost immediately — /. i\, within the first forty- 
eight hours — ^and persistently continued. The muscles of the 
shoulder should be massaged and treated by electricity. Abduc- 
tion should not be attempted to any great extent for some weeks 
after the operation for fear of displacing the upper end of the 
humerus too far from the glenoid cavity. The final results fol- 
lowing reduction and suturing have been, as a rule, excellent, 
useful arms resulting in most cases. The results following ex- 
cision are only fairly satisfactory. If the proper amount of bone 
has been removed, ankylosis will not occur. If too much bone 
has been removed, a dangling or flail joint will result. An ex- 
cision is to be avoided if possible. 



FRACTUKES OF THE EIUMEKI'S 



FRACTURES OF THE SHAFT OF THE HUMERUS 
Fracture of the shaft of the hunusrus may occur at any point 
between the surgical neck and the condyles (see Fig. 171). Its 
common seat is at the middle or in the lower third of the bone 
(see Fig. 172). Tiie twisting force exercised in the breaking up 
of adhesions in and about the shoulder- joint will often fracture 
a humeral shaft obliquely. The strength test of the arms, as 
seen in the illustration, has been the cause of spiral fracture of 
the humerus (see Figs. 173, 174). 




Symptoms. — The symjitoms are readily recognized. They 
re sucllin^ at the scat of fracture, pain, crepitus, abnormal 
notion, and ecchynioses. Paralysis of the musculospiral nerve 
nay oi^our, with the characteristic wrist-drop. Ordinarily, the 
.ltcnlii>n of both tlic patient and the surgeon is so occupied with 
he fr.Ktiux.' uf the Imne and its associated loss of movement that 
D^s of pi>\\er ami sensation, because of involvement of the 
lerve. -■ > inirii:ij;^'iii/,ed. if injury lo ihe musculospiral nerve is 
lot iiro.jni/eil iU the nutlet, it niav be overlooked until the 




tit- 173.— Trill of ilTcnEth 




146 FRACTURES OF THE HUMERUS 

splints are removed. The exact duration and the cause of the 
paralysis can not then be readily ascertained. The patient ma/ 
wrongly attribute the paralysis to the pressure of the splints. 
Very rarely, injury or pressure upon the large vessels of the arm 
is met with. Damage to the artery will be suggested by weak 
or absent pulse at the wrist or by local evidences of hemorrhage. 
A swelling appearing suddenly, greater than that which would 
appear from the laceration of soft tissues alone, should suggest 
rupture of large vessels. Measurement of the humerus should 
be made from the edge of the acromial process to the external 
condyle of the humerus (see Fig. 143). The amount of overlap- 
ping of the fragments will be shown by this measurement. 

Treatment. — For purposes of treatment, fractures of the shaft 
may be grouped into those with little or no displacement and 
those with considerable displacement and difficult of retention 
after reduction. The fracture should be reduced by traction 
upon the condyles of the humerus and countertraction upon the 
upper arm and by manipulation of the fractured bones. 

Treatment of Fractures of the Shaft of the Humerus with 
Little or no Displacement (see Figs. 175, 176). — The fol- 
lowing materials are needed for the apparatus to be used : Ordi- 
nary dusting-powder, — which is powdered oxid of zinc and pow- 
dered starch, equal parts ; a bandage of Shaker flannel three 
inches wide, not cut on the bias ; an axillary pad made with 
several layers of sheet wadding covered with a folded piece of 
pasteboard, and the whole inclosed in cotton cloth stitciied at 
the edges ; the pad is V-shaped, and long enough to extend from 
the apex of the axilla to just above the internal condyle of the 
humerus ; it is broad enough to support the upper arm comfort- 
ably and securely ; tiic lower part of the pad is about three 
inches thick (see Fig. 177), so as to support the arm only a 
trifle abducted from the side — that is, just away from the per- 
pendicular. If the axillary pad is too short, there is danger of 
causing an outward bowing of the humerus (see I'ig. 179). 
Two straps arc attached to the upper corners of the apex of the 
V-shapcd pad long enough to surround the body and go over 
the opposite shoulder. These straps iiold the pad in position. 
The remaining apparatus consists of two or tiirce thin coapta- 



14^ FKACIL-RES OF THE HUMEKL'S 

tion splints for application to the upper arm ; these are made 
quickly by laying thin splint wood upon adhesive plaster, and 
sph'tting the wood longitudinally (see Fig. 178); three adhe- 




Fig. 17a, — Conptalioih 

l?oii" Made bvtayiii'gi'hiH 
wood «n ndhKiv^ p>slrr 
nnd ^iilliling Willi knilr. 




sivc straps two inches wide to hold the coaptation splints; an 
adhesive plaster swathe wide enough to extend from the aero- | 
mion tip to the externa! condyle, and long enough to surrouni 



TREATMENT OF FRACTURES OF THE SHAFl^ 149 

the body and upper arm ; a cravat sling ; a thin towel or piece 
of compress cloth for the forearm to rest upon. Ail these 
articles should be in readiness. 

Etherization of the patient will rarely be necessary. In cases 
of nervous and sensitive women and unmanageable young 
children it will be wise to use an anesthetic. The whole upper 
extremity, axilla, and chest should be washed with soap and 
water, thoroughly dried, and dusted with powder ; then the 
reduced fracture is held in position by an assistant while the 
apparatus is being applied. The hand, forearm, and elbow 




ighl-anKk- splinl 



should be snugly and evenly covered by the flannel bandage (see 
Fig. 165). The upper arm should be surrounded by the coapta- 
tion splints, held in place by the three straps of adhesive plaster, 
so as to secure the fractured bone pxjrfectly {?.ec Fig. 175). The 
axillary pad should be placed in the axilla and held by the straps 
passed over the opposite shoulder and under the opposite axilla. 
The upper arm should rest comfortably upon the pad. To prevent 
chafing, the thin towel or compress cloth should be placed 
beneath the forearm where it touches the- body. The pla.ster 
swathe should then be applied over the arm to the body, so as to 



150 FKACTUKES OF THE HUMERUS 

encircle completely the trunk (see Hg. 176). Tiius the arm is 
absolutely fixed to the axillary pad and side. Tlie wrist should 
be supported in a cravat sling passed around the neck. The 
elbow is left unsupported. The weight of the upper extremity 
will thus tend to exert slight downward traction upon the lower 
fragment of the humerus. Under no circumstances should an 
ordinary broad sling be used, because of the danger of making 
upward pressure upon the forearm and elbow and so pushing up 
the lower fragment of the humerus. The elbow-joint should 
not be immobilized for the reason that it would then be much 
more difficult to hold the seat 
of fracture fixed. With the 
elbow-joint fixed, the lower 
arm of the lever is greatly in- 
crea'ied, and instead of move- 
ment of the forearm taking 
place at the elbow-joint it 
would take place at the seat 
of fracture. Fractures of the 
shaft of the humerus are 
frequently treated by an in- 
ternal angular splint and co- 
aptadon splints, the upper 
ends of the splints barely 
iibovc?fho»ViijtVKsoTupi!ir'«i"J'lowrr tmi's! reaching the fracture, or, at 

Heail o( bone lool;* in Ihe same Etntral direc- ^ ' 

i^^onii«iheim*rMauondyir,buisiigiiiiyfurihpr best, being an inch or two 
him"tu'"""* iraciui« of ihc shafi of tiir abovc it (scc Tig. 180). When 
the fracture of the bone is 
within the lower third of the shaft, then and then only should 
an internal angular splint be used in connection with coaptation 
splints. 

After-treatment. — The patient should be seen each day for 
the first three days in urder that the surgeon may be informed as 
to the exact condition of the jiarts. There may be undue pres- 
sure. The patient iiia\;bc uncomfortable. The splints may need 
readjusting,'. Attention to little details of dLsc(>mfort is impor- 
tant. The dressing sjioiik! he reapplied with great care once each 
week. Till' p.nls covered by splints should at each dressing be 




TREATMENT OF FRACTURES OF THE SHAFT 15I 

carefully inspected to detect any points of undue pressure, indi- 
cated by reddening of the skin. If these are discovered, they 
should be washed with alcohol and covered with flexible collo- 
dion or a drying powder. The undue pressure should be 
removed by shifting the padding. Union will be found to be 
firm after about three or four weeks. As soon as union is solid, 
— ^at the end of four or five weeks, — the swathe may be omitted, 
the coaptation splints alone being a sufficient support. After 
about five weeks or five weeks and a half all support may be 
removed from the arm. The arm is then put in the sleeve of 
the clothes, and the wrist supported by a sling. After eight 
weeks the sling may be discarded and moderate careful use of 
the limb in light movements be indulged in. 

Fracture of the Shaft of the Humerus with Considerable 
Displacement. — Obviously, the method described for the treat- 
ment of fractures without great displacement will be of compara- 
tively little value. Occasionally, it will be found that this method 
will hold even greatly displaced fractures ; it should then be 
used. The ideally perfect method for such cases is traction and 
countertraction upon the arm with the patient lying on the back 
in bed. Coaptation splints should be used, as in simple uncom- 
plicated fractures. If all methods fail to hold the fragments 
reduced, open incision, reduction of the displacement, and sutur- 
ing of the fragments are indicated. 

The plaster-of- Paris splint, applied with the plaster roller to 
the forearm and arm, and the spica bandage to the shoulder and 
chest are often efficient in these difficult cases. In the applica- 
tion of this splint it is of supreme importance that an assistant 
hold the arm so that the alinement of the bones remains perfect. 
The assistant who holds the arm should have nothing else to do. 
Before applying the plaster-of- Paris splint it is often advisable to 
apply thin coaptation splints at the seat of fracture to give addi- 
tional strength to the splint. With these coaptation splints in 
use a lighter plaster splint may be applied without sacrificing 
strength. A narrow cotton swathe about the body and arm 
should steady the upper extremity. The wrist should be sup- 
ported by a cravat sling. 

The after-care of a case treated by the plaster splint will be 



152 FRACTURES OF THE HUMERUS 

similar to Chat following any other treatment after union has 
occurred. The plaster may be left in situ for four weeks ; then, 
ordinarily, repair will be found so far advanced that the plaster 
splint may be dispensed with and the ordinary coaptation splints 
and swathe may be used. If the plaster splint has proved com- 
fortable, it may be split and reapplied. 

Massage and Passive Moii..n : In \icu ..>r ilir possibility of 

n 



nonunion of this fracture, it will be wise not to begin massage 
until union has begun. Passive motion to the shoulder and 
elbow should be gently made at as early a date as po.ssible, with 
due con.sideration to the condition of re|>air in the fracture. If 
at the end of three weeks union is found to have be^un. it will 
be wise to move the shoulder and elbow gently by pas5i\-e 
motion. The .seat of fracture should be cautiously guarded 
against movement during these gentle nianipulatioii.s. A little 



MUSCULOSPIRAL NERVE INVOLVEMENT I 53 

gentle passive movement of this sort repeated occasionally dur- 
ing the process of repair will assist very considerably in the 
restoration of the functional usefulness of the shoulder and elbow, 
which so often become stiff from immobilization. 

Prognosis. — Ordinarily, union occurs readily in from four to 
six weeks. In childhood union is quite solid in from three to 
five weeks. Fractures of this bone are more likely to be followed 
by nonunion than fracture of any other bone in the body. The 
presence of abnormal mobility after a considerable time (three 
months) has elapsed is the sign of nonunion by bone. Consider- 
able muscular atrophy follows this fracture (see Fig. 182). Upon 
using the arm again and by massage the size of the arm is, in a 
great measure, restored. The stiffness of the shoulder and elbow 
which is sometimes associated with this injury is due to long im- 
mobilization without passive motion. 

Fracture of the shaft of the humerus sometimes occurs in 
the new-born during delivery or afterward. The arm is best 
immobilized by thin coaptation splints. These splints may be as 
thin as six thicknesses of ordinary letter paper, and may be made 
of cardboard. The humerus is completely surrounded by them. 
They are held firmly by adhesive-plaster straps. If they are cut 
the right length and width, they may be applied most efficiently 
without padding. A liberal amount of drying powder should be 
rubbed on the arm and chest. A piece of compress cloth should 
be placed on the side of the chest under the injured arm, to pre- 
vent chafing. The upper arm is then held to the side of the 
chest by a gauze or other cloth swathe. Repair is rapid. Union 
is firm in about three weeks. Fracture of the humerus in the 
new-born is sometimes associated with obstetrical paralysis of the 
upper extremity. This obstetrical paralysis should not be con- 
founded with musculospiral paralysis. 

The Musculospiral Nerve in Fracture of the Humerus. — 

The musculospiral nerve may be involved in fracture of the 
humeral shaft, particularly if the fracture is at the middle or in 
the lower third of the bone. The nerve lies in the musculo- 
spiral groove of the humerus. It leaves the bone a little below 
the junction of the middle and lower thirds of the arm (see Fii^^ 
183). The nerve may be involved primarily at the lime of the 



154 



FRACTURES OF THE HUMERUS 



accident by the contusion or laceration caused by the original 
violence or by the pressure of bony fragments. The nerve may 
also be involved secondarily by the pressure of the bony callus 
or of the cicatricial tissue of the soft parts. 

Symptoms. — Contusion of the musculospiral nerve may be 
slight or severe. If slight, there will be pain at the injured place, 
and a tingling and numbness along the distribution of the nerve. 
These symptoms may pass away quickly or the tingling may 
remain several days. If it remains, a chronic neuritis is estab- 
lished associated with shooting and neuralgic pains. If the 
contusion is severe, there will be complete anesthesia and com- 
plete paralysis of the nerve below the place involved. This may 
pass away early or it may remain several months or it may be- 




Fig. 183.— Relations of musculospiral nerve on outer side of arm (from dissected speci- 
men) : a. Clavicle ; d, deltoid ; c, pecioralis major ; d, biceps ; ^, brachialis anticus ; /", triceps ; 
g^. musculospiral nerve. 



come permanent. Pressure upon the nerve from callus, cicatri- 
cial tissue, and bony fragments will give signs of disturbed sen- 
sation and motion in the parts supplied by the nerve. 

Compression of the Musculospiral Nerve : The musculospiral 
nerve supplies the triceps, brachialis anticus, supinator longus, 
and extensor carpi nidialis longior muscles. Inability to extend 
the fingers and wrist and loss of supination are the usual signs 
of motor paralysis following compression of this nerve. As for 
sensation, lluic will be complete loss or impaired sensation in 
the lower half of the outer and anterior aspect of the arm and in 
the middle of the hack of the forearm as far as the wrist. 

Treatment. — lininecliate paralysis does not necessarily mean 
jncssure h\' a l)on\' fra^^inent. Such paralysis may be associated 



; OF THE ELilOW 



155 



with contusion ; tlicrefore, operative interference should be 
delayed. If the symptoms persist for four or five nioiuhs, ex- 
posure of the nerve and relieving, if possible, the conditions 
found are indicated. It is wise to allow the fractured bone to 
unite before operating. 

The prognosis after the removal of pressure and following 
resection and suture of the musculosjtirai nerve is good as to 
the ultimate partial or complete recovery. After a few days or 
weeks sensation will return, After a few montlis — five to eight 
— motion will begin to return (sec Figs. [.S4. 185. I S6). 



E 



ul"u 



Halignaat Disease. — Carcinoma is said to have occurred sec- 
ondarily in a fractured bono, Sarcoma develops in the callus of 
fractures. It is highly probable that in many of the so-called 
.sarcomata of callus tite disease preexisted in the bone, and was 
the reason for the fracture occurring after trivial injury. 

FRACTURES OF THE ELBOW 
Fractures of the lower end of the h umerus near lo and involving 
the elljow-jointare frequent in childhood, but much less frequent 
in adults. A familiarity with the bony landmarks of the elbow 
is essential to an accurate diagnosis. The more ntarly accurate 
the diagnosis, thL- more efficient will be the treatment ami the 



!^ 






/ 
/ 




Loose fragment of 
shaft. 



- Condyle of humerus. 



Fig. 185.— Same as figure 186. Lateral view to show displacement of fragment 

(X-ray tracing). 




I 

— i — Upper fragment of 
. numerus 



— Middle l<x>se fragment. 



Lower fragment. 



Mk. 18'';. — I)"iil>!c Iracturc oi the humerus. Paralysis of the musculuspiral nerve. Im- 
im<liaie uiin»ii <>t hone. Suture ol nerve found caught between fraj^ments. Gradual recovery. 
Same as fi^iure 185 1 X-ray tracinj^j". 



■56 



EXAMINATION OF THE ELBOW 



157 



more intelligent will be the prognosis. Every elbow injury, no 
matter how trivial, should be examined under anesthesia. 

Method of Examination. — The normal anatomical relations 
of the uninjured elbow are to be first determined. The large 
prominent internal condyle of the humerus, the olecranon pro- 
cess of the ulna, the external condyle, the head of the radius are 
each in tum to be grasped by the thumb and forefinger. If 
these bony points can be recognized upon the injured elbow, 
then a fracture ought not to be overlooked. 

The Three Bony Points of the Elbow Region : With a pencil 
or ink the internal and external condyles of the humerus and 




Fig. IST.—Ttie re at ont of he Ih et bouy poinli at the elbow in cxlciiiian ami in Hexion 
(fiom behind). The mark> are plsced upon Ihe Inlemal and exleriiBl cuiidt l» aiid olecianon 
procen (diagram). 

the tip of the olecranon should be marked, the forearm being 
extended. Normally, these three points will be found to be in 
nearly a straight line transverse to the long axis of the limb. The 
tip of the olecranon is a trifle above this line (see I'igs. 187, 188), 
Palpation of the Three Bony Points : Grasping the left wrist 
with the left hand, place the right thumb upon the external con- 
dyle, the third finger on the internal condyle, and the forefinger 
on the olecranon. When the elbow is at a right angle, the.se 
three points will be found in the same plane wltJi the back of the 
upper arm. A similar examination may bo made of the right 
elbow, changing hands for convenience (see Figs. 187, 189). 



EXAMIHATION OF THE HLUUW 1 59 

The Head of the Radius (see Fig. 193) ; Grasping the e]bo«- 
with one hand, the thumb resting one-half an inch below the 
external condyle upon the head of the radius, and holding the 
wrist in the other hand, the patient's forearm is pronated and 
supinated. If the shaft of the radius is unbroken, the head nf 
the radius will be felt to move under the thumb. 

The Carrying Aii;'lt.' ('■'ee Fi;;;>i. iQn. tiyi): The lateral angle 




that the supinated forearm makes with tiie upper ann is called 
the carrying angli;. It is important to remember that this angle 
varies normally within very wide limits. Some individuals have 
no carrying angle. Its presence or absence is of little functional 
value. 

Movements at the Elbow-joint: The movements of the joint 
should be deternihied both in flexion and extension. There is 
normally no later.il motion in the extended elbow-joint. Abnor- 



i6o 



FRACTURES OF THE HUMERUS 



mal lateral motion in either adduction or abduction should be 
detected if present. 

Measurements : The distance between the two condyles 
should be measured on the uninjured arm. The distance from 




the acromial process to the external condyle of the humerus 
should also be measured (see Fig. [43). 

Having' then establi.shed a standard nf comparison in the 
normal elbow, the injured ell)OW should be examined with the 
{greatest care, luen when there is L;rcat swelling of the elbow 



EXAMINATION <»F Till! KI.BOW 



161 



region, steady pressure will enable tlie fingers to reach the con- 
dyles. In approaching an injury to the elbow the questions 
which arise are: Is there a dislocation? Is there a fracture? 
Are both dislocation and fracture present ? Is there a con- 
tusion and a sprain? Is there a subluxation of the radial 
head ? In the absence of positive signs of dislocation, subluxa- 
tion, and fracture the lesion i^ a sprain or contusion. In the 



absence of positive signs of dislocatimi ami ivhImI ■■nl'ii. 
fracture will be present. 

Summary of the Order of Examination of the Injured 
Elbow. — Notice whether the swelling and eccliymosis arc general 
or localized. If localized, that maj' determine the seat of tlic 
lesion. Observe the carrying angle. Palpate the external and in- 
ternal condyles (see Fig. 193), the olecranon process of the ulna 
(see Fig, i94),andthelicadoftheradius(see Fig, 192). Determine 
if crepitus is present. See if the head of the radius rotates. Note 



J 



EXAMINATION OF THE ISJUKED ELBOW I63 

the relations of the three bony points, with the forearm flexed at 
a right anfjleand completely extended (sec Figs. 187, i8S, 189), 
Note any lateral motion at tiie elbow-joint (see Fig, 195). Deter- 
mirie the possible movements of the elbow-joint. Make measure- 
ments. 

The traumatic lesions of the elbow may be grouped, for sim- 
plicity and ease of reference, in the following manner. During 
the roiilinc examination it is wise to have in mind these possible 
individual lesions : 

Ix^sions of the Radius and Ulna : {a) Dislocation of the radius 




and ulna backward with or without fracture of the coronoid pro- 
cess of the ulna. 

(d) Subluxation of the radial liead. 

(<r) Fracture of the olecranon process of the uhia. 

(1/) Fracture of the neck or head of the radius, 

Lesions of the Lower Fjid of the Humerus : (1) Fracture of 
tile internal epicondyle (see iMg, 196, c. c), 

(/) Fracture of the internal condyle (see Fig. iy6, /', /'), 



1 64 

(i"") Fracture of the external condyle (see V\^. 196, d,d). 

{Ii) Transverse fracture of the shaft of the humerus above 
the condyles (supracondylar) (see Fig. 197, a, a). 

(i) Separation of tiie lower epiphysis of the humerus. 

{k) T-fracture into the elbow-joint (see 196, a, a, a, and Fig. 
197. b. h. I>). 

Symptoms of Lesions About the Elbow-joint with the 
Differential Diagnosis of Each Lesion. — {ti) A Dislocation of 
the Radius and Ulna Backward with or without Fracture of the 
Coronoid Process of the Ulna : There may be very great swelling 
of the region of the elbow. The relations between the three bony 
points arc disturbed. The olecranon process is very prominent 





iixi 



ViK. i96.-T-rraciure, high In, ". ai. Fig. i97.-Suiiracon<lyloid f 
Ftaclure ol inleni»1 con.lylc 1*, »1. Fiai- T-ftaclur* low donn (*, *. 

liirc of inlcmal ipiconilj-le |i, ')• Fracluri' 
uf eiurnat condyle yd. d) (diaitraml. 



posteriorly. The radial head is displaced backward. The two 
condyles are far in front of the olecranon. There is abnormal 
lateral mobility. The normal movements of the joint are re- 
stricted. This injury may bo mistaken for a supracondylar 
fracture. The important difference has been mentioned. A dis- 
location of h()th bones backward, if reduced, does not ordinarily 
tend again to become displaced ; if it does, there is mo.st likely 
a fracture of the coronoid process of the ulna. 

(/') Subluxation of the Head of the Radius: Tliis takes place 
ill chiUiit-n iiiidir tlve years of a^^e. It is due lo ■sudden traction 
upon the extended forearm, whieli so often occurs in lifting a child 



DIAGNOSIS OF KLCOW-JOINT LESIONS l6: 

by the arm over a curbstone. The child presents the arm Iiang 
ing slightly away from the side, with the elbow a little flexed i 
and the hand semipronated. Attempts to use the arm cause 
pain. The extremes of flexion and extension and supination are 
painful. Inspection will detect a slight swelling one-half of an 
inch to an inch below the external condyle of the humerus. Ten- 
derness is present over the head of the radius. The relation of 







the three bony prominences is preserved. The details of this not 
uncommon lesion are mentioned because it is sometimes mistaken 
for a fracture of the radial head or a simple sprain of the elbow. 
A fracture of the radius below the neck has also been mistaken 
for this subluxation of the head. , Careful detailed examination 
will alone clear up anj' doubts. 



i66 



FRACTURES OF THE HUMERUS 



(c) Fracture of the Olecranon Process : The details of this frac- 
ture arc considered elsewhere. Crepitus and mobility of the olec- 
ranon fragment will be felt. There may or may not be separation 




--\ — - Internal condyle. 



Fig. 199.— Normal right arm of patient in figure 19S (X-ray tracing). 



Internal condjlo. 




External condyle. 



f— Capitellum. 



—J 4 Radius. 



Mi;. -^ . .-- 1 iat.;iiu' «if iiittinal « cndyle of left humerus. Rt-covery with deformity. Sec 

liKOic ly*^ I X-ray tracing). 

o'tlif tVi^Mncnts. If tlicrc is a separation, it will be detected and 

tlic tiircc bony points will liavc their normal relations disturbed. 

{f/ ) I'ractiirc of the Neck or Head of the Radius : This is un- 



DIAGNOSIS OF ELBOW-JOINT LESIOSS 167 

common. Swelling over the radial head and neck is present. 
Supination and pronation are painful and limited and attended 
by crepitus, muscular spasm, and possibly a loss of rotation of 
the radial head. 

(c) Fracture of the Internal Kpicondyle : The epiphysis of this 
epicondyle unites to the shaft of the humerus between the eigh- 
teenth and twentieth years. This fracture is quite common 
among little children. If this fracture presents a small fragment, 
it is of little consequence. If a large fragment is broken off", it is 
of consequence. The displacement is downward and forward. 




The ulnar nerve is sometimes, though rarely, implicated in this 
injury. 

(/) Fracture of the Internal Condyle ; Swellingoverthis con- 
dyle is marked. By grasping the condyle abnormal mobility and 
crepitus are detected between the fragment and the shaft. The 
inner of the three bony points is displaced upward. Lateral 
mobility of the elbow is present ; adduction is especially free. 
The carrying angle will be diminished if there is displacement of 
the condyle upward (see Figs. 198, 199, 200). 



1 68 



FRACTURES OF THE HUMERUS 



(^) Fracture of the External Condyle (see Fig. 202): Swell- 
ing over this condyle is marked. Crepitus and abnormal mobility 
are present. The normal relations of the three bony points are 
disturbed. The external condyle is displaced upward. The 
relation of the external condyle and the head of the radius is 
undisturbed. Lateral motion at the elbow is or is not present. 
The transverse measurement of the elbow is greatest on the 
injured side. Supination will be somewhat limited. 

(A) Transverse Fracture of the Shaft of the Humerus Above 
the Condyles. Supracondyloid Fracture (see Fig. 203) : The line 
of this fracture is higher up on the shaft than the line of the 




-- External condyle. 
- Capitellum. 

Upper radial epiphysis. 



\ 

Fig, 202.— Fracture of external condyle of humerus. Child five years of age. Nucleus for 

capitellum seen below fragment. 



epiphysis. A fullness will be noticed in front of the elbow- 
joint, and [)osteriorly the point of the elbow will appear prom- 
inent. The small lower fragment is displaced backward with the 
bones of the forearm ; the upper fragment or shaft of the 
humerus is displaced forward, causing the fullness in the bend of 
the elbow (sec Fig. 205). The three bony points maintain their 
normal relations. This distinguishes the fracture from a disloca- 
tion of both hc^nes backward (sec Fig. 206). Crepitus will be 
detected upon grasping the arm firmly above and below the 
elhow-joint (see I'ig. 195). Recurrence of the displacement often 
follows its correction unless the fracture is properly immobilized. 



lo B [ighl inglc. DUtT>m la 




DIFFERENTIAL UIAGKUSI5 



Abnormal lateral and anteroposterior mobility above the elbow- 
joint is found (see Figs. 203, 204). 



Humeral tbafl. ^ 



"A/ K\ 1 

^'^ \ i Y-^ Epii,j,„i,. 




Fig. J07,— DIipUci 



'dt."ph>si..°"chiiy«vin'iMtiof"g"?X."yi^cinRr" """"" " 







Fig. »«.— Sh'i.s 
Ho9|>ilal. i^s). 



(i) Separation of the Lower Epiphysis of the Humerus ; The 
lower epiphysis of the humerus unites to the shaft about the 



FRACTURES OF THE HUMERUS 



seventeenth year. It includes only the very lowest end of the 
humerus. The lower epiphysis of the humerus is made up of 




the external epicoiidyle, tlic capitelhim, and the trochlea. These 
separate centers of ossification luiitc about the thirteenth year, 
and at about the scveiitcentli year thuj- join the sliaft of the bone. 



DIFFERENTIAL DIAGNOSIS 



The epiphysis of the internal epicondyle is entirely separate from 
the large, general, lower, humeral epiphysis. 




T3[ cpiphys 



This is it not uncommon accident. It occurs usually in chil- 
dren under ten years old. Tlicrc is no change in the relations 
of the three bony points. It somewhat resembles transverse 



1/4 



FRACTURES OF THE HUMERUS 



fracture above the condyles. The diagnosis is made upon the 
following points : The age of the individual : the histon* of 
the accident : the existence of abnormal mobilitv at a ver\- low 
level on the humeral shaft ; anteroposterior mobility- ver}- 



Oiecranon fossa. — — — ^__ 



Interna] portion of 
epiphysis. 



Ulna. — — ^^^ 




Humeral epiph>si« and 

— — bits from the ^iapli>- 

sis. 
CaiMtellura. 

— - - Radial epiph>-sis. 

— — Radius. 



Fig. 213. — Separation of the lower epiphysis of the humerus, after nnioa Anterofkos- 
terior view. This 6j(ure illustrates the fact that the epiph\sis does not inclade the condjr;cs 
of the humerus X-ray tracing). 




United humeral 

epiphxsis. 

Capiielinm. 



R;iilial epiph>sts. 

Fjc -.1 — Se'virAttoii of :he lower huniera! epiph\s:-, after un:on. Lateral view. Exsensioa 
Ti-.-rnii! Flex on t-j a ritiht anjs:!e > X-ray trac.ni; Massachusetts General Hospital. :5«?t. 



marked. lateral mobility being less marked ; muffled crepitus 
thi- term i- ver\- >uijL:estivc. and i> used bv Poland). The 



ftO 



b''c.iii::i -»t" the i'»'Aer i::\d of the humeral fragment is broader 
tii.i!! i:: the ca>e ot" a fracture isee Figs. 207 to 214 inclusive). 



DIKFEKENTIAL DIAGNOSIS 



'75 



(i) T-fracture into the Elbow-joint (see Figs. 215, 2i6, 217): 
The traumatism which causes this injury may be extremely slight. 
If the two condyles are grasped, crepitus and abnormal mobility 
will be detected. The relations of the three bony points will 
be disturbed, according as one or both condyles are displaced. 
The transverse measurement of the condyles will be found to be 
increased. There will be abnormal lateral mobility, both in 
adduction and abduction. 

A systematic anatomical examination of injuries to the elbow- 




under an anesthetic will overcome much of the indefiniteness that 
surrounds these injuries. A crushed elbow, feeling to the ex- 
amining hand like a bag of bones, can not always be accurately 
diagnosed, some of the details of the lesions naturally remaining 
undetermined. The Rontgen ray in these doubtful cases will be 
of material assistance. The importance, however, of making such 
a careful eliminative examination as is described, both from the 
point of view of treatment and prognosis, can not be overesti- 
mated. 



176 FRACTURES OF THE EIUMEKUS 

Treatment. — The object of treatment is to restore the elbow- 
jt)int to its normal condition. If the fracture is attended by- 
great sweUing, it will be necessary to temporarily support 
the arm until the swelling reaches its maximum and begins to 
subside. The right-angle internal angular splint is the most 
satisfactory for this purpose (.'^ee Figs. 218, 2ig). The maxi- 
mum swelling will have taken place after forty-eight to seventy- 




pitti of Iiii is foWcci (wtih vise mid liammirl: ft shows ilic lienil in the back tidge complcied 
Ibcnl wilhp1ic[s,hamni«r«l dose in liievisir); f. the i-ompletecl splint with edges slii|<ed and 




ighl-a.igle splint 



two hours. This tenipoi-ary dressing will rarely be needed. In 
general, it may be staled that the arm should be placed in that 
position in which it is found, upon experiment with the fracture 
under consideration, that the fragments are best held reduced. 

J'nic/iiirx of flic internal ifiit>ii<{yh\ of l/if iiKtrnal condyle, of 
the cxtcniiil coiiihlc. mrd J-frnctiires into the joint are best 
treated, as a rule, in the acutely flexed position. 



TKEATMEST OK FRACTURES OF THE El.nOW 1 77 

Experimental evidence, both upon the ciidavcr and on the 
anesthetized living subject, confirmed by clinical experience 
extending over a number of years in the hospital and private 
practice of many different surgeons, demonstrates that the acutely 
flexed position actively reduces and holds reduced the fractures 
previously mentioned. In the acutely flexed position the cor- 
onoid process in front, the trochlear surface of the olecranon 
behind, and the fascia; posteriorly and laterally, together with the 



tKgini 




*fore aiiplving 



tendon of the triceps posteriorly, hold the fragments reduced 
and close to the shaft of the humerus. 

Method of Using the Acutely Flexed Position : The coniiyles 
of the humerus are grasped by the thumb and finger of one hand, 
a finger of the other hand is placed in the bend of the elbow, trac- 
tion is made upon the forearm, and it is slowly flexed to an acute 
angle. While the forearm is being flexed, traction and lateral 
pressure are brought to bear njion the loose fragments of the 
humerus to correct existing malpositions. These manipulations 
will materially assist in the reduction (see I'ig. 230). 

The degree of flexion will be determined bv the obstruction 



178 FRACTURES OF THE HUMERUS 

offered by the local swelling. If the swelling is great, or is likely 
to increase very much, then the degree of flexion must be less 
than when there is no swelling. In the bend of the elbow, to pre- 
vent chafing, is placed a piece of gauze upon which lias been 
dusted a dry powder. This acutely flexed position is maintained 
by an adhesive-plaster strap, three inches wide, passing about the 
arm and forearm (see Fig. 2^0. This strap should be placed 




upon the upper arm as high as the axillarv- fold, and upon the 
forearm just above the styloid of the ulna. A piece of linen or 
compress cloth (cotton cloth) is placed under the forearm and 
hand where they would come in contact with the skin of the 
chest. This should be pinned so as not to slip from position. 
The arm thus flexed is supported by a swathe sling (see Fig. 2 1 3) 
made of cotton ciolh, fifteen inches wide, folded three times, and 



TKKATMKNT Of FKACTLiRES OF THE ICLBOW I79 

long enougli to extend twice around the body. This is applied 
as illustrated (see Figs. 222, 223). The elbow is held to the 
side by pinning a strip of compress to the swathe at the elbow 
and posteriorly (see Fig. 223). 

Precautions in Using the Acutely Flexed Position : The arm is 
inspected each day for the first week. It is necessary to note 
whether with the increase in the swelling the flexion of the arm 




should be diminished, and whether with diminution in the swell- 
ing flexion may be increased with safety. The radial pulse 
should be felt as the flexion Is diminished, so as to avoid com- 
pression of the vessels at the bejid of the elbow. There should 
be no pain associated with this acutely flexed position. A cer- 
tain amount of discomfort may be complained of. Real pain 
will be indicative of too great pressure, and if it is present, the 
forearm should be less acutelj' flexed. Chafing should be 



FKACTt'RF-S OF THE HUMERUS 



looked for at llie bend of the elbow, under tlie forearm and 
hand and on the chest, where, if necessary, fresh powder and 
compress cloth .should be placed. The edge of the adhesive 
plaster may cause chafing of the skin upon the posterior sur- 
face of the forearm and upper arm. It may be necessary to 
place beneath the plaster small, carefully folded compresses of 
cotton cloth to protect the skin (see Fig. 222). 




I 



Later, in changing the adhesive plaster, the skin may be 
washed with alcohol and then with soap and water, to the great 
comfort of the patient. The alcohol removes all adhesive plas- 
ter slicking to the skin. If the adhesive plaster chafes the skrn. 
as it so often docs in children, it will be necessary to place a bit 
of gauze under the adhesive-plaster strips, leaving enough of 
the sticky side of the plaster uncovered lo catch tlit- skin and 



■IKEAl'MENT OP FKACTUKI^S OF TilE EIM>\\ 181 

thus keep it from slipping entirely loose. Tlie carrying anglt 
of the arm will be preserved if the fragments are approximately 
reduced : it can not be maintained otherwise. The acutely flexed 
position reduces the fragments in the fractures under considera- 
tion ; therefore it will preserve the carrying angle. 

Trans^'crsc Fracliirc of the Shaft aboi.-f the Condyles. — There 
is usually an overlapping of the fragments. This is evident in 
the backivard di.splacemcnt of the lower fragment and forearm 
and in the forward displacement of the upper fragment. 




It will be necessary in order to effect reduction of this frac- 
ture to make, with the aid of an assistant, countertraction and 
pressure backward upnn the upper fragment while traction and 
a forward pull are made upon the lower fragment by grasping the 
arm above the condyles (see Fig. 220). The internal right- 
angle splint will best hold this fracture, for it exerts continuous 
pressure backward upon the upper fragment and prevents dis- 
placement {sec Figs. 325, 226). It is padded with sheet wad- 
ding and applied as illustrated. Two straps are needed upon 



tS3 kractures of the humerus 

the forearm to hold this splint in good position (see Figs. 22y, 
228). The strap at the wrist should be so applied that there is 
no pressure upon the styloid process of the ulna. Long-continued 
pressure upon this bony process would cause a pressure sore. 
In applying the adhesive plaster it is wise to apply it so loosely 
that there is no undue pressure upon the arm. which might re- 
tard the circulation. The arm is then covered with a roller 
bandage of sheet wadding, over which is placed a roller bandage 
of cheese-cloth. This should be applied smoothly and firmly 
from the hand to the upper end of the splint. As the swelling 




illj or'lii"e"elbow"(i« V\^l^\ 



about the elbow begins to subside, pads of cotton cloth (com- 
press cloth) may be placed at each side of the olecranon below 
each condyle. The pressure of a frequently renewed bandage 
on these pads will hasten the disappearance of the swelling. It 
is important to avoid the forward and backward deformity in 
treating this fracture (see Figs. 229, 230, 231). 

Dhlocfition of Both Hones 0/ the Forcarin Backivard. — If there 
is no tendency to displacement after reduction is accomplished, 
the right-angle position with internal splint is the best treatment. 
If, on the other hand, there is a tendency to displacement, the 
acutely flexed position will be the best for the arm because in 



TKKATMENT OF FRACTURES OF THE ELBOW 



■S3 



case the coronoid process is broken it will insure its close approxi- 
mation to the ulna. 

SeparatioH of the Imvcr t-piphysis of tlic huiinnis will be best 
treated in the right-angle position, the same as a fracture of the 
humerus above the condyles (see Figs. 210 and :;i3). 

Fracture of the neck of the riu/ius is best treated by the iiucrnal 
right-angle splint. 

Fructuri: of tin- olecranon is discussed elsewhere. 

The After-care of Injuries to the Elbow. — The reapplying 
of splints and of apparatus .should be done often enough lo be sure 




that they are efficient, and that there is no undue swelling or 
pressure upon the arm. Rebandaging the hand and the arm 
each day. if the internal angular splint is used, is important. All 
a|>paratus should be removed at least once a week, and carefully 
ins|}ected twice during this interval. Passive motion should be 
instituted late rather than early. In mo.<;t instances it will be 
wise to delay passive motion until union is firm — from the fourth 
to the .sixth week. It should be of the yentlest sort ; passive 
motion that is painful does harm. 

Massage to the hand, wrist, forearm, elbow, and upjjcr arm. 



1 84 



FRACTURES OF THE HUMERUS 



after the primary swelling has begun to subside, is of great value. 
It should be given at first without disturbing the apparatus and 
the retentive adhesive plaster. Given every otlier day, it will 
accomplish considerable in maintaining the integrity of the 
muscles of the part. The employment of a professional mas- 




Fig. 229. — Supracoiidyloid fracture. Ob- 
liquity of the line of fracture from behind 
downward and forward. Diagram show- 
ing anterior deformity with elbow Hexed. 




Fig. 230.— Supracoiidyloid fracture. Ob- 
liquity of the line of fracture from above 
downward and backward. Diagram show- 
ing posterior deformity if acute flexion of 
forearm is attempted. 




Fig. 231.— Supracondyloid fracture with slight anterior displacement, wired. Recovery. 
with slight anterior bending of fragments. Wire seen in situ (X-ray tracing. Massachusetts 
General Hospital, 1077). 



seusc is not always necessary. The physician should give the 
massage or instruct a competent person how to give it. 

Omission of Splint or Retentive Apparatus : This should be 
tentative and gradual after union is known to be firm — in the 
fifth or sixth week. The arm should be allowed in a sling with- 
out the splint for an hour and then the splint applied. The fol- 



THE PROGNOSIS OF FRACTURES OF THE ELliOW 185 

lowing day a longer interval Js granted without the splint. 
Gradually, the splint is removed entirely. A snugly fitting band- 
age will often prove comfortable as a support on first leaving off 
the splint. Passive motion, massage, and active use of the arm will 
now assist in regaining the use of the joint. At this stage the 
carrying of dumb-bells, pails or baskets filled with sand, and the 
doing of certain gymnastic movements with the injured arm 
will be of materia] aid. Al! violent exercise of the part is to 
be avoided. That amount of exercise may be allowed that 





leaves the arm moderately tired. A fatigue that is not recovered 
from within a half-hour's rest is excessive. 

The Prognosis. — Up to the time of the present introduction 
of the acutely flexed position in the treatment of fractures at the 
elbow, the movement most easily lost and with greatest difficulty 
regained was that of flexion. By the use of the acutely flexed 
position in suitable cases the prognosis has improved remarkably 
in this respect. Now all of flexion is ordinarily preserved, and 



1 86 FRACTURES OF THE HUMERUS 

the more easily acquired extension is obtained as usual, so that 
the prognosis as to motion in these cases is good. Although ana- 
tomically perfect results are not always obtained, most fractures 
of this region recover with a useful arm. These fractures of the 
elbow region should be kept under observation for at least four 
months. It is wise to treat such cases until all that can be 
achieved toward a restoration of function has been accomplished. 
At the time of the first examination of the elbow the nature 
of the injury and its seriousness should be explained care- 
fully to the patient or his friends. A guarded outlook should 
be expressed, particularly with reference to the function of the 
joint. Some limitation of motion may exist after all that is pos- 
sible has been done (see Fig. 232). How much limitation of mo- 
tion will exist it is impossible to state. There may be none what- 
ever. The patient and his friends should be encouraged with the 
statement that just as great usefulness of the elbow-joint will be 
obtained as is consistent with the character of the injury. The 
importance of the injury demands of every physician a painstak- 
ing anatomical examination with the aid of an anesthetic, careful 
attention to minute details in the initial treatment, and intelligent 
solicitude in the after-care of all traumatisms to the elbow-joint. 



CHAPTER X 
FRACTURES OF THE BONES OF THE FOREARM 

FRACTURES OF BOTH RADIUS AND ULNA 

The most common seats of fracture are in either the middle 
or lower thirds of the bones. The fracture of the radius is 
often a Httle higher than the fracture of the ulna (see Figs. 233- 
238 inclusive). 

Symptoms. — The arm can not be used without pain. In a 
muscular or fat arm with little separation of the fragments there 
may be no deformity excepting the localized swelling at the seat 
of fracture. Deformity will be determined by the displacement 
of the bones. If the seat of fracture is not obvious, the fore- 
arm should be grasped by the two hands (see Fig. 239) and 
gentle but firm movement attempted, to determine the pres- 
ence of abnormal motion and crepitus. Motion should be at- 
tempted in all directions, for the bones may be fractured and 
yet be locked when movement is made in one direction only. 

Incomplete or Greenstick Fracture of the Bones of the 

Forearm (see Figs. 240, 241, 242). — This is a partial break 
across the bone, with bending at the seat of fracture. In children 
between the ages of two and fourteen years injury to the bones 
of the forearm results usually in a greenstick fracture. Either 
one or both bones may be broken. One bone may be completely 
fractured while the other is incompletely broken. 

Deformity is very evident. Pain and tenderness at the seat 
of fracture are present. Crepitus is absent unless one bone is 
completely fractured. Children having these fractures are often 
seen a week or two after the injury ; they are said to have 
*' sprained the arm " and " are unable to use it well at the pres- 
ent time." Careful inspection will detect the characteristic bow- 
ing at the seat of a greenstick fracture. Slight callus will be 

present if a little time has elapsed since the injury. 

187 



FRACTURtS OF BOTH KADIUS AND ULNA 1 89 

Fracture of the Neck and Head of the Radius. — These 
fractures are rarely unassociatcd with lesions of the humerus and 
uhia. A fracture of the external condyle of the humerus and 
backward dislocation of both bones of the forearm have been 
noted with these fractures. 




Loc;d swelling and tenderness over the radial head and neck 
are apparent. The swelling is greater than in a simple subluxa- 
tion of the radius, and is limited to the upper third of the radial 
side of the forearm. There is pronation of the forearm. Flexion 
and extension, in the absence of associated lesions such as frac- 
ture of the external condyle of the humerus, are possible. At- 



I go 



FRACTURES OF THE BONES OF THE FOREARM 



tempted rotation of the radius, — that is, supination, — elicits pain, 
muscuiar spasm, and perhaps crepitus. The head of the bone does 
not usually rotate with the shaft, at least not as it does normally. 
Subluxation of the radial head and fracture of the external con- 
dyle of the humerus are the two lesions with which a fracture of 
the radial neck and head is most often confused. The points of 
difference have been indicated. The X-ray is here of decided value. 
It is often difficult on account of overlying muscle and swelling 
of the soft parts to palpate the head of the radius with accuracy. 
Pressure over the shaft of the radius at about its middle elicits 







pain, if a fracture of the radial neck be present, at the seat of 
fracture. An X-ray of the elbow will determine a diagnosis. 

Fracture of the Shaft of the Radius (see Figs. 246-251 
inclusive). — This is usually caused by direct violence. The 
fracture occurring at any part of the shaft presents no unusual 
symptoniH. The head of the bono docs not rotate with the shaft 
unless the fragments are locked. Abnormal mobility, pain, and 
crepitus are present. The displacements vary with the situation 
of the fracture. I'ronation and supination will be limited and 
painful. This fracture has been mistaken for a subluxation of the 
radial head. A fracture of the radial .shaft at the junction of the 



FRACTURES OF BOTH RADIUS AND ULN'A 



191 



lower and middle thirds will sometimes suggest very plainly the 
lateral deformity in a Colles' fracture, the prominent ulna and 
apparently shortened styloid process of the radius being in evi- 
dence. If the fracture occurs in the upper third of the bone, 
the displacement of the upper fragment will be considerable. 

Separation of the Lower Epiphysis of the Radius (see Fig. 
252). — The lower radial epiphysis unites to the shaft of the bone 
at the twentieth year. Previous to this age a separation of the 
epiphysis is not at all uncommon. Many cases of separation of 



— Common dlipl: 




this epiphysis are thought to be Colles' fractures, and they are 
treated as such. The treatment of the two conditions is much 
the same, but there is less difficulty in maintaining the frag- 
ments in position in separation of the epiphysis, and the epiphyseal 
separation requires a shorter time in splints. 

A soft, cartilaginous crepitus is felt. There are usually less 
swelling and less pain than in a Colles' fracture. The deformity 
is quite constant : a prominence near the carpus on the dorsum of 
the wrist and a prominence higher up on the palmar surface of 





roreami Bl ihe middle. showiiiK tailing id- tnnum, showing difTrnncn in IevcI am 

SeilKr or broken endi (X-ri>* truing). ihii ihc Kat olfTadure ii in ihelomr ihin 




FKACTUKES OF BOTH RADIUS AND ULNA 1 93 

tlie wrist. There is almost no tendency to reproduction of the 
deformity after it is once reduced. 

Fracture of the shaft of the ulna occurs usually because of 
a direct blow received upon the arm raised for protection. It 
is more uncommon than fracture of the radius (see Figs. 255, 256, 
257). 

Localized tenderness, pafn upon attempting to use the fore- 
arm, obscure discomfort in the ami after an injury — these may be 
the only signs of fracture. There is no general .swelling of the 
forearm. Ordinarily, there will be very little displacement, 
because the radius serves as a splint for the broken bone. Crepi- 




tus may be detected if the ulna is grasped between the lingers, 
placed either side of the fracture, and motion is attempted. The 
shaft of the ulna being subcutaneous thiou^'hout its entire extent. 
the tender seat of fracture can be ea.'iily determined (see Fig. 258). 
Fracture of the coronoid process of the ulna is associated 
with backward dislocation of the ulna. It is a rare accident. A 
very small fragment is broken off] and it is not much displaced. 
If in any dislocation of the forearm backward recurrence of the 
deformity after reduction occurs readily, a fracture of the coro- 
noid should be suspected. This will be confirmed by the dis- 
covery of a small hard mass in front of the tibow-joint just 
above the insertion of Ihe brachialis anticus muscle ; rouglily, a 



194 FRACTURES OF THE BONES OF THE FOREARM 

fingcrbreadth above the bend of the elbow. This small hard 
mass may give crepitus upon being manipulated. It is very diffi- 
cult to detect this fragment of the coronoid process even under 
the most favorable conditions. The Rontgen ray may discover it. 
Treatment of Fractures of the Forearm. — The objects of 




treatment are to pre\ent permanent deformity and to preser\-e 
the movements of pronation and supination. 

Fractures of Both Radius and Ulna. — All fractures of the 
forearm attended with overriding or angular displacement that do 
not yield readily to traction, countertraction, and pressure should 



HOI r^n 



FIB. af5-«'.B'>l fote- . Fig. i46.-FraetuK of radius. Kig. 147 -'■■'■»':"" 

"am fto""i!ld"im™"'id1II Rgw uj'x-ray'S^tg)" ' ' leropoi'iMiot .fiiplac. 

showing epiphvs«s Lchil J af mciit (same » Fie.iMi 

cighl yean (Warren Mu- X-ray uacliig). 




TKEATMEXT I97 

be reduced under complete anesthesia. While an assistant makes 
countertraction upon the upper part of the forearm the sui^eon, 
holding the lower end of the limb, makes strong, even traction, 
at the same time pressing the bones into position. When the 
angular deformity is corrected, the forearm should be strongly 
supinated. This supination will assist in preventing the bones 
becoming locked close together (see Fig. 261). 

In order to immobilize a fracture of the shaft of a bone not only 
must the fracture itself be held firmly, but the joint immediately 





above and below the seat of fracture must be immovably fixed. 
If the arm is seen immediately after the accident, and the soft 
parts are not evidently bruised, and there is little swelling, a 
plaster-of- Paris splint should be applied. It should extend from 
the axilla above to the metacarpophalangeal joints below The 
arm should be flexed to a right angle and the forearm semi- 
supinated (thumb upward) (see Fig. 362), 

Precautions in Using the Plaster -of- Paris Splint : The forearm 
should be held in the corrected position by an assistant through- 
out the application of the plaster bandages. Two assistants will 



igS FRACTURES OF THE BONES OF THE FOREARM 

facilitate the putting on of the plaster. The forearm and upper 
arm should be thinly covered with one layer of sheet wadding ; 
cotton wadding should not be used. No salt should be used in 
the water in which the plaster bandages are dipped. It will 
require about three or four bandages, three inches wide and four 
yards long, for an ordinary muscular adult arm. The plaster 
roller should be applied deliberately, evenly, and snugly from 
the metacarpophalangeal joints to the axilla. Great lateral com- 
pression of the arm will be avoided if the bandage is applied as 





licd IcnJerness clinically Ihe mily Bvmp- 
loni(Mi»tiicliu>etls(icri«ralHnsi>UBT, 1036. 
X-IByl racing). 



directeH. There will be insufficient compression to crowd the 
bones together and so produce deformity. 

After-care of the Plaster Splint : When the plaster has set 
firmly, the assistant may place the forearm in a sling of comfort- 
able height to support the arm. Inspection of the fingers will 
determine the condition of the circulation in the limb. If there 
is too great pressure, if the splint is too tight, a bluene.ss will ap- 
pear, indicating a sluggishness in the circulation. If this sign ap- 
pears, the splint should immediately be split from axilla to hand 



TREATMENT 



'99 



by a knife. This will relieve the circulation. Ordinarily, there is 
no difficulty of this sort. The patient should be seen each diiy for 
the first week after the dressing is put on. Inquirj' should be 
made for pain and throbbing in the arm and sleeplessness, which 
are evidences of too great pressure. If the ;irm is doing well, 
the splint should cause no discomfort. After one week the 
plaster splint should be removed, for the swelling of the arm 
will have diminished and the splint will have become loosened. 
Unless this loosening is corrected, an opportunity for deformity to 




cl violence. No crepllus dc- 
only lyaptom* (X-ray Inning). 




jnsiiinble [itersl displa'ceTiiei'ii ind 

horleniiie of shaft (X-ray tracinR. Massa- 
huKlU General Hospital, 5693). 



occur will then exist. Either a new plaster should be applied or 
the old splint, if suitable, should be reapplied and tightened by a 
bandage. If the splint is too large, it may be made smaller by 
removing a strip of plaster the entire length of the splint. The 
edges of the cut plaster should be bound with strips of adhesive 
plaster to prevent chafing of the skin and crumbling of the plaster. 
The position of the bones at the seat of fracture should be noted. 
The degree of movement possible at the seat of fracture should 
be noted. At the end of each week the .splints should be re- 



FkACTCRF,S Of THE hOSF-^ OF THE FOKEAKX 



m'.v'j'i. After alx>ut three weeks, when union is weU ad^-anced, 
the pla-itf.T '-fdint may be cut off Fxriow the elbow and the upper 
part (ii-^carrltfi, or a p<'isterior splint of wood may be appi^d for 
lighlncsH and convenience. 

If th<: force wai a direct violence and there is injurj-to the soft 
f«*rt=i,if the swcMinfj is cfmsiderable and is likely to be greater, it 
will tic tx;st to use pi^lmar and dorsal splints of wood upon the 
forearm i^nd an internal right-angle spHnt at the elbow. The 
forearm is held in the [x^sition of scmi.supination. The maximum 
swellinfj occurs within the first forty-eight hours — barring, of 



Wi 




,.,as; 



•''«■ W— Showing; diiuncc b« 



Ci.i 






course, inflammatory disturbances, which are not to be considered 
here. The splints should be of thin splint wood, which is stiff 
enough not to yield to ordinary pressure. In width they should be 
one-fourth of an inch wider than the forearm. The posterior splint 
should extend from just above the middle of the forearm to the 
metacarpophalangeal joints. The anterior .splint should extend 
from ihe same point on the fiirciirni to the middle of the palm of 
the lianil (.see I-'ig. 361). The palmar splint is cut out on the 
thumb side, .so as to avoid pressure on the thenar eminence. 
These two splints are j)a<lded with evenly folded sheet wadding 
no wider than the s|(lints. About three or four thicknesses of 



TKEATMEXT 



the sheet wadding will be necessary. The posterior splint is 
padded alike through its whole extent The anterior splint is so 
padded as to conform to the irregularities of the anterior surface 
of the forearm, particularly at the radial side near the wrist. The 
internal right-angle splint is padded evenly with four thick- 
nesses of sheet wadding. It overlaps the wooden splints, and 
extends up to the axilla. It immobilizes the elbow-joint. 




Fir. >6o.— V'arlilions in thcsliapc >ntl widlli orihcintcroHcoui space belKirenra'liui and 
ulns when tbe lovtxrm ii tupinsled, piotiatecl. and seniipronated. ScmipronRlion prrsenli 



The Application of the Splints : The forearm is held flexed at 
a right angle and semi-supinated and steadied by an assistant. 
The posterior and then the anterior .splints are applied to the 
forearm. Three straps of adhesive plaster, two inches broad, 
are then applied — one at the upper ends of the splints, one at the 
wrist, and the third across the palm of the liand and around the 



302 FRACTURES OF THE BONES OF THE FOREARM 

posterior splint only. These straps should simply sleatiy the 
.splints snugly in position (see Fig. 263). The bandage is 
next applied, and it is by this that pressure is exerted upon the 
arm. There should be some spring left upon pressing the 
splints together after the bandagt- is applied. If there is none 




remaining, too great pressure will be made on the arm and the 
circulation will be interfered with. The arm is placed in a sling 
of comfortable height (.see Fig. 363). 

If the fracture of the forearm is above the middle of the bones. 
the tin internal right-angle splint should be used to immobilize the 



i 



TREATMENT 



303 



elbow-joinl. Tliis should he applied after the wooden splints 
are in place and while the arm is semisupinated, A bandage is 
then placed over both wooden and tin splints (see Figs. 264, 265, 
266). 

After-cart; of Wooden and Tin Splints : The patient should be 
seen every day for two or three days after the fracture. The 
splints should be readjusted and applied more snugly by a fresh 
bandage. The comfort of the patient should be considered ; 




any complaint on the part of a sensible individual should be 
inquired into. If the apparatus is applied with the bones in 
appro>dmately normal position, there should be no subsequent 
discomfort. All splints should be removed at least twice a week 
throughout active treatment, and the presence of deformity noted 
and corrected. After the first week or week and a half, the 
swelling having subsided, it is often advantageous to apply in 
place of these splints of wood the plaster-of-l'aris splint, which 
has been described (see p, T97), 



204 



FRACTURES OF THE BONES OF THE FOREARM 



Fracture of the head and neck of the radius and fracture 
of the coroitoid process of the ulna should be treated by the 

intemai right-angle splint with the forearm semipronated — that 
is. with tlic thumb up (see Kig. 266). 

Fracture of the shaft of the radius, if above the middle of 
ihe boiie, should be treated by the iinterior and posterior wooden 
splints and the internal right-angle splint. If bciow the middle 
of the bone, the internal right-angle splint may be omitted, 
although it may be well to retain it in most instances. If the 
fracture is in the ii|)per third nf the bone, it may hv inipo.'^sible 




to correct the deformity without making an open fracture and 
suturing the fragments together. It may be possible to ap- 
proximate the fragments by putting the forearm in a position of 
semipronation. No especial splint is necessary to maintain this 
position : the two wooden anterior and posterior splints and the 
tin internal right-angle splint fulfil all the indications. 

Separation of the lower radial epiphysis is treated by ante- 
rior and posterior splints, similarly to the treatment of a Colles' 
fracture (st-e Fig. 261). 

Fracture of the shaft of the ulna should be treated as frac- 
tures of the shaft of the radius are treated. 



TKUAIMliNr 305 

How lung should splints be kept on in fractures of the fore- 
arm ? Until union is firm enough between the fragments, so that 
firm pressure does not cause motion. When the fracture is firm, 
ordinarily after about three weeks and a half, the anterior and in- 
ternal angular splints may be omitted, the posterior splint alone 
being left in place. If the posterior splint of wood is used, a 
broad (four-inch) strap of adhesive plaster, in addition to the two 
ordinary straps at each end of the splint, should be placed at the 
seat of fracture and a gauze bandage applied over all. At the 




and tin internal Biicularsplliii!i. 1 anil I, Sirsps holdliiB 
d s, strapi balilliic iiilcrnul rlglilitnglc ipllnl. 



end of the fourth or fifth week all splints should be omitted. 
Continual watchfulness is demanded in order that bowing at the 
seat of fracture may not take place. The application of the 
sling after the omission of splints should be carefully made to 
avoid backward bowing of the bones. A laboring man should 
not go to work for at least from four to six week.^^ after leaving 
off" splints. A return to work too early causes bowing of the 
fracture and pain in the arm. 

Massage and passive motion should be employed as soon as 
union is firm and the anterior and internal angular splints have 



I 



2or> 



FK.ACrLiRES OF THE 



■■ THE FOKEAKM 



been rLTnoved. Massage maj' be given at first without removing 
the arm from the splint. Convalescence will proceed more rap- 
idly in consequence of massage. 

When wilt the arm be restored to normal usefulness ? It is im- 
possible to answer this question accurately. The conditions in 
each individual instance of fracture are so variable that no gen- 
eral statement can be made that will more than indicate the 
probable time of convalescence. It may be fairly stated that in 
an uncomplicated fracture of both bones of the forearm the 
arm will be useful for working in from two to three months 
from tlie time of fnicture. 







The treatment of open fractures of llie forearm is best con- 
ducted by methods described under open fractures of the leg : 
briefly, absolute cleanliness, suturing of bones, sterile dressing, 
immobilization of the part. 

Prognosis and Result of Treatment. — There may be some 
limitation of supination and pronation immediately after the 
splints are removed. As the callus diminishes and with persist- 
ent movements of the arm in ordinary use tliis limitation should 
diminish, and in some instances entirely disappear. If the frac- 
ture is in the upper or lower thirds of the bones, the limitation 
of motion will often be greater than when the fracture is at the 



l-kOi.SOSrS AND RESULT OF TREATMENT 



207 



miLiiile of the bones. The interosseous space is greatest at the 
middle of the shafts (see Fig. 360) ; consequently, callus at this 
point is less likely to impair motion of the forearm. The arm 
should be straight. Movements of the wrist and elbow should 
be perfectly normal. 

Nonunion ol Fractures. — If after the usuaI time has elapsed 
for a fracture to haM.- luiiicl tlrnih- it has failt*! of union, delaved 



S 



union is said to exist. If after a longer time no union occurs, 
nonunion is said to cxi.'^t, A case of delayed union may result 
in nonunion or it may become united. The term nonunion 
does not, however, necessarily imply tliat no union exists be- 
tween the bones, but simply that bony union does not exist. In 
cases of so-called nonunion fibrous union is often present. 
The causes of nonunion are local and genera!. Of the local 



PROGNOSIS AND RESULT OF TKEATMENT 



309 



causes the commonest is the interposition of some soft tissue, 
such as torn periosteum, strips of fascia or muscle, between the 
fragments. A wide separation and imperfect immobilization of 
the fragments are also factors in the occurrence of nonunion. 
Of the general causes it is thought that syphilis, pregnancy, 
prolonged lactation, the wasting disease-s. rachitis, and the acute 
febrile diseases may contribute something toward nonunion. 

The constitutional treatment of nonunion is of primary impor- 
tance, together with reduction and absolute immobilization of the 
fragments. If these measures fail after a fair trial, a rubbing of 
the ends of the fractured bones together and tlien immobilizing 




them is sometimes effective. If this fails too, operative meas- 
ures should be instituted for making the fracture an open one 
for the removal of any interposed tissues. Careful fixation will, 
after such operative procedure, usually effect union. If for 
some unremediable constitutional reason union does not result 
after operation, a splint should be devised to make the damaged 
part as useful as is compatible with nonunion. 

Treatment of Qreenstick or Incomplete Fracture of the 
Bones of the Forearm. — It is impossible to maintain the cor- 
rection of the deformity if the bones are simply bent back into 
position, liven with the greatest care in the use of pads and 



2rO FRACTURES OF THE BONF--^ OF THE FOR£.\RM 

pressure the deformity will in part reappear. It is necessary, 
therefore, to administer an anesthetic, and to make a complete 
fracture of the greenstick fracture. This done, the arm is set as 
in a complete fracture. The best method of refracturing the 
green stick fracture is to bend the arm with the two hands in the 
direction of the original force (see Fig. 270). 

The anterior and posterior wooden splints may be used with 
satisfaction. Ordinarily, the plaster-of- Paris splint as applied in 
complete fractures is the best apparatus. Union in children after 
fracture is more rapid than in adults. At the end of two weeks 
union will be found firm. It is well not to omit all apparatus 
in a child until four weeks have passed. If great caution is 
needed on account of an extremely active child, the posterior 
wo<xlen splint should be kept on during the fifth week. 



FRACTURES OP THE OLECRANOT4 

The normal anatomical relations of the olecranon should be 
kept constantly in mind. The insertion of the brachialis anticus 
muscle is into the front and lower part or base of the coronoid 
process of the ulna. The insertion of the triceps muscle is into 
the posterior part of the upfxrr surface of the olecranon and into 
the fascia of the posterior surface of the forearm. The small 
epiphy.sis of the olecranon unites to the shaft about the sixteenth 
year. A direct blow upon the olecranon together with \'iolent 
muscular contraction of the triceps will produce the fracture. The 
fracture is usually transverse. A complete transverse fracture 
of the olecranon always opens the elbow-joint (see Fig. 271). 
Some of the varieties of fracture of the olecranon are seen in 
the accompanying tracings of Rontgen-ray plates (see Figs. 272, 

273. 274, 275). 

Symptoms. — Inability forcibly to extend the forearm, pain at 
the seat of fracture, and deformity, provided the fragment is 
separated from the shaft of the ulna. A depression marks the 
separation. Very great separation of the fragment is not often 
present. The interval between the fragments depends upon three 
conditions : The extent of the facial laceration — if the laceration 
is moderate in extent, the interval between the fragments will be 



FRACTUKES OF llIE OLECRANON 



slight ; if the laceration is extensive, the inlcrv.il between the 
fragments may be great ; the position of the arm, whether flexed 



— S|>liiilercil 




or extended — if flexed, the separation will be greater than if 
extended (see Fig. 276) ; the amount of synovial fluid and blood 
in the joint — the greater the amount of fluid, the greater will be 



212 



FRACTURES OF THE BONES OF THE FOREARM 



the separation of the fragments. The mobility of the fragments 
of the olecranon is determined by grasping the olecranon firmly 



Radius. 



Coronoid process. 



Ulnar shaft. 




4- Hu 



merus. 



Olecranon. 



Seat of fracture. 



Fig. 273. — Fracture of olecranon. No displacement detected clinically. No symptoms other 

than local tenderness and slight swelling (X-ray tracing). 



Humerus. 



Olecranon. 




IMnar shaft. 

l'"iK- -^TJ- — Fraciure of olectanon; separation of fragments upon flexing forearm (X-iay 

tracing). 

and attempting lateral motion (.sec Tig. 194). Crepitus may thus 
be elicitt'd. The general swelling about the elbow will be con- 



TREATMENT 



siderable if the traumatism was severe. There exists a traumatic 
synovitis of the elbow-joint. 



Fin- iTS-Diagi 







Treatment. — If there is considerable sweUing of the elbow, 
and if the arm is large and muscular, it is wise to rest the arm 
for a few days (at least five or six) upon an internal right-angle 



214 FRACTURES OF THE BONES OF THE FOREARM 

splint before putting it up permanently. The swelling will dis- 
appear in the mean time, and a more accurate examination of the 
arm can then be made. If there is little or no separation of the 
fragments in the right-angle position, the arm may be kept at a 
right angle. This is doubtless the most comfortable position, 
and. under these conditions, certainly is effective. If there is 




marked separalion (half an inch or more), the arm should be 
extended and this position maintained by a long internal splint 
(see Fig. 277). This splint, made of splint-wood, should be the 
width of the arm, and should reach from the anterior axillary 
margin to the tips of the fingers. This is well padded with 
sheet wadding at the bend of the elbow (see Fig. 37S). The 
contiguous skin surfaces of the fingers are protected fmm chafing 



by strips of gauze or compress cloth placed between them, and a 
pad is put in the palm for comfort (see Fig. 279). The splint is 
held in position by four straps of adhesive plaster, one placed at 
either end of the splint and one above and below the elbow-joint. 
The upper or loose fragment is puslied down toward the shaft of 
the ulna, and held in place by a strap of adhesive plaster carried 




around the upper side of the olecranon fr;igment and fastened to 
the splint lower down. Sheet wadding and gauze roller bandages 
applied from the fingers to the axilla afford comfort and prevent 
undue swelling of the hand. Should the separation be so great 
that reduction of the fragment is unsatisfactor>', an incision and 
suture should be made (see Fig. 279)- 

Tr,-atinait if the l-mclurc is O/'eii.—Thc wound shoid.l, if 



FRACTURE;- 



TiiE rOREARM 



necessary, be enlarged to permit of easy inspection of the 
joint surface. The joint should be thoroughly irrigated 
witli boiled water. The wound of the soft parts should be 
very tlioroiighly cleansed by scrubbing with gauze wet in cor- 
rosive sublimate solution, I : 5000, and then the fragment of 
the olecranon sutured tn the shaft. 



Q 



FiK. 179.— Fnrture of olecf inon. Bandage niiplled 10 the unw on sa uliowii 
:7s. N'ole I'rolecllDi) □{ fingers rroin chsliiii I'y coDi|>rc» cloth and handii|ti 



i;:ra" 



The After-care. — If tiie arm has been put up temporarily at a 
light angle to await the subsidence of the swelling, gentle mas- 
sage and firm bandaging of the arm, twice daily, until the swell- 
ing subsides sufficiently for accurate examination and a more 
permanent dressing, will be of very great service. The arm 
should be inspected each day for the first week. IJaily massage 
should be continues! not only to the joint region, but to the fore- 



r upper arm as well. The straps and bandages should 
be reapplied as they become too tight or are loosened by tlie 
disappearance of the swelling. After about two weeks the posi- 
tion of the forearm may be cauliously changed. The small 
fragment of the olecranon should be held fixed during the ma- 
nipulation. If the arm is in the extended position, it should 
be gradually flexed some five or ten degrees, and returned 
to the extended poMtion. If the arm 11 already at a right 




■llit°taeh«dof''lheul'nL*Tbc racial a>' ulnaT The ilvroiiTof Uie ndiui i 

)nld [■ <«n Id be lower Ihsn Ihe Imcl al INbd t>ie ilytord of llir uluii. 



angle, it should be gradually extended, at first a few degrees 
only, and returned to the right-angle position. No pain should 
be experienced by the passive motion. Painful passive motion 
is harmful. After a few days of these gentle passive motions it 
will be wise to alter the angle of the splint so that the arm 
may rest in the changed position permanently. After about 
four or five weeks all splints should be omitted. A bandage 
should be worn after ihi.- removal of the splints to afford suppoii 
to the elbow. 



2l8 



FRACTURES OF THE BONES OF THE FOREARM 



Union of the fragments usually takes place in from three to 
four weeks. After six weeks to three months the movements of 
the elbow-joint should be normal. There may remain as a per- 
manent condition slight limitation of extension. The functional 
usefulness of the elbow depends more upon the approximation 
of the fragments and less upon the kind of union between them. 
The union between the fragments is more often ligamentous 
than bony. A short fibrous union, if of good width, — /. c, if it 
covers the whole of the broken surface, — is as efficient as a bony 
union. A ligamentous union accompanied by great disability in 





Fif^. 38a.— a. Tip of radius: b, styloid process of ulna; c, ulnar head. i. Supination. 2. 
Pronation. To illustrate that, in comparinK the level of the styloid of radius with lower end 
of ulna, as in figures 280, 281, in supination, i, the head o^ the ulna is felt, and that in prona- 
tion, 3, the styloid oi the ulna is felt. 



the functional usefulness ot the arm should be excised and the 
bony fragment sutured to the shaft. Suturing of the periosteum 
and fibrous tissue about the fragments will prove fully as satis- 
factory in many cases as suturing the bone with silver wire. 

Summary : If there is great swelling, delay the application 
of the permanent splint. Apply internal right-angle splint. 
Use compression and massage. If there is little or no separa- 
tion of the fragments, use a right-angle splint. If there is 
marked separation of fragments, use an extended position. If 



COLl.t^a KKACTUKE 2I9 

the fr.-icture is open, suture tiie fragments. If practicable, at 
the outset, renew the bandage and massajje the arm twice daily. 
After two weeks cautiou.s passive motion should be made daily. 
After three weeks the angle of the splint should be permanently 
changed. After four weeks all splints should be removed. 
After six weeks to three months a useful arm should result. 

Tetanus is rarely seen after fracture of bone. It sometimes 
appears after o|)en fracture. I-^rly amputation and the adminis- 
tration of tetanus antitoxin arc the most rational means of treat- 
ment in these cases. 

COLLES- FRACTURE 

A fracture of the lower end of the radius within about one 
inch of the articular surface is common in adults and is unusual 
in childhood. A fall upon the outstretched and extended hand 
is the most frequent cause. 

Anatomy. — In a case of traumatism to the wrist the normal 



^^J^f 



anatomical relations should be studied upon the uninjured wrist, 
and then a careful examination made of the injury. The normal 
wrist should be looked at from the front and back and from each 
side with the hand supinated. Anteriorly, the base of the thenar 
eminence is lower than that of the hypothenar eminence. Pos- 
teriorly, on the inner side, the styloid process of the ulna is 
visible with the marked depression below it. I-aterally, on the 
radial .side, is seen the curve backward on the anterior surface of 



FRACTURES OK ' 



, HONES OF THE FOREARM 



the radius where the base of the styloid process of the radius 
joins the shaft. Laterally, upon the ulnar side, are seen not only 
the styloid of the ulna and its associated depression, but the 
hollow above the prominence of the hypothenar eminence. 

The normal wrist should be felt with the hand both in supina- 
tion and pronation. With the hand supinated (see Fig, 280) the 
tip of the styloid process of the radius is found to be lower 
(nearer the hand) than the head of the utna. With the hand in 
pronation (see Fig. 281) the tip of the styloid process of the 




radius is found to be a little lower {nearer the hand) than the tip 
of the styloid process of the ulna. To ascertain the relative posi- 
tion' of the styloid processes, the injured wrist should be gra.sped 
by the two hands and the styloids felt by the tips of the fore- 
fingers. The -Styloid process of the radius and the shaft imme- 
diately above it should be carefully palpated to determine the 
extremu thinness of the bone above the thick styloid process 
{see l-'ig. 283). The width of the wrist between the styloid pro- 



COtLES FRACTURE — ANATOMY 23 I 

cesses should be measured by means of a tape, or, better, by a 
pair of calipers. 

The movements of llie normal ivrist and forearm shoidd be 
carefully observed. I'ronntion iiiid supination of the forearm 




and flexion, extension, abduction, and adduction of the hand 
should be carefully performed. These simple observations 
quickly made upon the normal wrist enable one to establish a 
standard for comparison with the injured wrist. In every ca.sc 



223 FRACTURES OF THE BONES OP THE POKEARM 

in wliicli there is a question of fracture the examination sliould 
be made by means of an anesthetic (see Fig. 283). If for suf- 
ficient reason complete anesthesia is contraindicated, primary an- 
esthesia will prove to be suPficient. In the larger proportion 
of cases of Colles* fracture primary anesthesia will be satisfactory 
for both the examination and the first dressing of the fracture. 

Symptoms. — In Colics' fracture the wrist appears unnatural. 
The thenar eminence of tlie thumb is higher, nearer to the wrist 
than usual, as compared with the hypothenar eminence (-jee Fig. 



I 




biwM bill [urLtaUy Teducnl 
Sllglil laienl dclotmHy. 




291). Anteroposterior and lateral deformities are apparent to a 
greater or less degree. It is said that at times an anterior dis- 
placement of the lower fragment occurs, the reverse of the ordi- 
nary displacement. It is unusual (see Fig. 284). 

The anteroposterior deformity is caused by the projection of 
the lower end of the upper fragment into the palmar surface of 
the wrist, pushing the flexor tendons forward (see Fig. 2S5), 
and by the projection of ihe upper end of the lower fragment 
toward the dorsal surface of the wrist, pushing the extensor 



COLLES FRACTURE SYMFltlMS 233 

tendons backward. Impaction of the radial fragments may be 
another factor in the production of the deformity. This deform- 
ity is spoken of by the older writers as the silver-fork deformity. 
The reason is obvious (see Figs. 286, 287, 288. 289, 290). 

The lateral deformity (see Fig. 291) is caused by several fac- 
tors : the impaction of the radial fracture, lateral displacement of 
the lower fragment, and by rupture of the inferior radio-ulnar 




"■"■"™-'/>Ci' 



>r fi|[urp J94 (Mdiiiacliuscas <j«iieiaL Hi 



ligaments. The abduction of the whole hand, the prominence 
laterally of the lower end of the ulna, the disappearance of the 
ulnar head from the dorsum of the wrist, arc to be noted. Because 
of the displacement of the radial lower fragment, the nonnal rela- 
tions are no longer maintained between the .styloid processes of 
the radius and ulna. There is a reversal of relations. The 
radial styloid is higher than usual. It is on the same level with 
or higher than the head of the ulna. 



224 



FRACTURES OF THE BONES OF THE FOREARM 



It is possible to have present a fracture of the lower end of 
the radius (a Colles' fracture) without any appreciable alteration 
in the levels of the styloid processes. The existence of the 
normal relations of the styloids does not preclude the presence 
of a fracture. 

Lower radial fragment rotated. 
I Scaphoid. 




I-.4-I 



I 

Radius. | 
Ulna. 



4- 
I 

I 
I 
Carpus 



4- 
I 



First metacarpal. 



Styloid of radius. 



Fig. 294.— Colles' fracture. Lateral view of figure 293. Rotation of lower fragment on trans- 
verse axis. Cause of dorsal and palmar deformity evident (X-ray tracing). 



Lower fragment of 
r.tdius. 








Fig. 295. — Simple transverse CoUes' fracture. Anteroi>osterior view. Lateral deform ily 

(X-ray tracing). 



Direct pressure over the broken bones elicits pain, but crepitus 
is often undetected until the patient is examined with the aid of 
an ancstiietic. A transverse rid<^e is sometimes present on the 
posterior and external surface of the radius, corres[)ondingto the 
line of fracture. In certain cases of Colics' fracture the wrist 



226 



FRACTURES OF THE UONES OF THE FOREARM 



may not appear very unnatural. There may be scarcely any 
deformity. The normal relation may be nearly preserved. If 
there is little displacement of the fragments, it may be difficult to 




u fiRure 195 (Miuichu- 



dctt-Tniine tlic existence of fracture. An appreciation of slight 
differences from the normal will, undor these circumstances, 
prove of yreat value. The Ri'iut^cn ray will be of service in 
this cnnnection. 



COLLES' FRACTURE DIFFERENTIAL DIAGNOSIS 227 

After injury to the wrist one must consider in the differential 



A iprain of the wriji, 

Conlusion of the bones near the wri: 
Dislocalion of the wrist backward. 



Fracture of the shaft of one or both boni 

low down, 
SepBralion of the lower ladial epiphysis. 



A sprain of the wrist is rather unusual. There very often 
exists in so-called sprains a definite anatomical lesion of bone. 
The deformity due to the distention of the synovial sac with fluid 



Fig. lOD.— CoUel' fmclure 
iiylold frasnitnt. Shaft of 




is conspicuous over the back of the wrist-joint and, therefore, near 
the hand. There is tenderness upon pressure over the synovial 
membrane anteroposteriorly. There is little or no tenderness 
over the radius upon deep pressure. There is an absence of the 
positive signs of fracture. It is not an uncommon experience 
to find an injury to the lower end of the radius presenting no 
positive fracture signs, which is proved by the Rontgen ray to 
be a break of the lower end of the radius. A lesion somewhat 
re.sembhitg that shown in figure 292, the bone being cracked 



225 FRACTURES OF THE BONES OF THE FOREARM 

along those same lines but without displacement, is found to 
exist, ^4anyof these obscure lesions are passed over as sprains 
of the wrist. Any injury to the wrist, no matter how trivial, 
should be regarded with suspicion until there is absolute proof 
that fracture is absent. 

A Contu.sion of One or Both Bones near the Wrist-joint : 




Tenderness i.s localised. 
Runtgen ray will 



Fracture sii^n.s are all absent. The 
1 determining this diagnosis. 
Dislocation of the wrist backw.ird is rare. The posterior 
prominence is lower down on the wrist than in CoUes' fracture. 
The iipjjor surface of the displaced carpus can be felt. The rela- 
tion of tlie two styloids is pre.servcd. The deformity disappears 



COLLES' FRACTURE— 



ITIAL DIAGNOSIS 



229 



and does not tend to reappear when traction is made on the hand 
and pressure is made over the dorsal prominence. 

Fracture of the shaft (see Fig. 305) of one or both bones 
low down may simulate the anteroposterior deformity of Colles' 
fracture, but an absence of other positive signs is important. 



Rtulial cpiphyiii, oi 




Tiie Rontgen ray determines the exact seat of the lesion. Ab- 
normal mobility and crepitus are readily obtained without the 
administration of an anesthetic. 

A Separation of the I^wer Epiphysis of the Radius : 
The lower epiphysis of the radius unites with the shaft about 



COLI.es fracture ASSOCIATED LESIONS 



231 



the twentieth year. The radius increases in length chiefly 
through growth from its lower epiphysis. This lesion occurs 
much more commonly than has hitherto been supposed. It 
is usually classed as a Colles' fracture, no very careful exam- 
ination being made. There is usually less deformity than is 
found in most CoUes' fractures, and it is nearer the hand. The 




creptius is soft and cartilaginous, and easily obtained without 
anesthetic. The treatment of separation of the lower radial 
epiphysis is similar to that of a Colles' fracture. A fracture oi 
tlie lower radial epiphysis is occasionally seen ; it is, however, 
rare lesion (see Fig. 304). 

Associated with every Colles' fracture there may be one < 
more of the following lesions : A fracture through the lo^v^ 



:tukhs of the ltI)N^:5 of '. 



end of the ulna, which is rather rare (see Fig. 305). A fracture 
of the styloid process of the ulna, which occurs in about fifty to 
sixty-five per cent, of all cases (see Fig, 300). A rupture of the 
interarticular triangular fibrocartilage at its insertion into the base 
of the styloid process of the ulna. This is probably quite com- 
mon, and accounts in part for the broadening of the wrist-joint. 
A perforation of the skin by the lower end of either the ulna or 
the shaft of the radius, makinij an open fi-acture. A fracture of 
the scaphoid bone, although occurring often alone, is not very 
commonly a.ssociated with Colics' fracture, A sprain of the 
hand, wrist, forearm, elbow, or shoulder may occur. It is wise 
; whole upper extremity, particularly a few days 




after the accident, as it is at this time that sprains associated 
with fracture arc likely to be felt. 

Treatment. — The ordinary uncomplicated fracture is here 
under consideration. Reduction should be accomplished as 
soon as possible. Complete reduction can not be made satis- 
factorily without the administration of an anesthetic, either to 
complete or partial anesthesia, Verj' great force is needed to 
accomplish satisfactory reduction of impacted fractures of the 
radius. It is because of the use of too little force that often a 
slight bony deformity remains after union has taken place. 

A iWethod of Reduction. — Grasp with the thumbs and fore- 
fingers of the two hands the upper and lower fragments. Free 
the lower fragment completely from the upper by pressure and 



COIXES FKACTLKE IKEATMliNT 



^ii 



traction backward and forward and laterally upon the lower frag- 
ment, using all the force that is needed (see Figs. 307, 30«). 
The lower fragment may then be forced into position by pressure 
of the two thumbs upon the dorsum of the wrist (see Fig. 309). 
When reduction is completed, the hand should be allowed to 



I 




rest naturally without support to determine whether there is n 
recurrence of the deformity. If there is no recurrence of the de- 
formity, the fracture may be fixed. If there is recurrence of the 
deformity, notice should be taken of the direction of the displace- 
ment of the loiver fragment, that proper pads may be applied to 
hold it in Rosition. A pad of compress cloth placed on the dor- 



2 34 



FRACTURES OF THE HONES OF TH 



sum of the wrist over the lower fragnieiit will easily hold it if or- 
dinarily displaced. A knowledge of the direction of the displace- 
ment of the lower fragment will suggest the prevention of the 
recurrence of the deformity. The Rontgen ray is making pos- 
sible a more intelligent treatment of this fracture of the radius. 
The bone is so nearly subcutaneous that one can lake advantage 
of an accurate knowledge of the line or lines of fracture in 




at Ihe inlcrioi ipllnt to dexr Ikn thonai eminence. 




attempting reduction of the malposition. Intelligently applied 
force can now be used in each fracture instead of the hitherto 
blind routine manipulation .s. Thus, less injurj' is done in set- 
ting the fracture, and better anatomical results are obtained. 

It is well to restore, if possible, the prominence of the lower 
end of the ulna at the back of the wrist. Usually, after a Colics' 
fracture has healed and functional usefulness is restored to the 



■RACTURE TREATMENT 



235 



wrist and hand, the ulna will be found to have slumped forward 
— to have disappeared from the dorsum of the wrist. This can 
be corrected somewhat by p;idding the ulna anteriorly and by 
completely correcting the radia! deformity and strongly adduct- 
ing the hand. 




Retentive Apparatus. — The simplest splint is the best. If 
there is considerable swelling about the seat of fracture in a 
rather muscular and large arm, it is best to use the following 
apparatus : Two pieces of spUnt-wood, one for the back and the 



236 FHAcrUKES 01- THE BUNEH UK THE I'OKEAKM 

other for the front of tlie forearm, are provided. The back or 
posterior splint should extend from the heads of the metacarpal 
bones to a little above the middle of the forearm (see Fig. 3 lO). 
The front or anterior splint should extend from the heads of the 
metacarpal bones to a little above the middle of the forearm (see 
F'g- 3' ')■ These splints are padded evenly and smoothly with 
sheet wadding, retentive pads at the scat of the fracture being used 
as needed. The hand and forearm are held in scmipronation. The 
hand is adducted. The' dorsal splint is applied and held in posi- 
tion. The anterior splint is then applied with the pads, and all are 
held in position by adhesive -plaster straps. The arm and splints 
are covered with a bandage. Direct pressure should be avoided 
over the head and styloid process of the ulna posteriorly, in order 







to minimize tlie disappearance of the bone from the dorsum of the 
wrist. A pad placed anteriorly and laterally over the lower end 
of the ulna is often useful in reducing the ulnar head and styloid. 
The adhesive -plaster straps should be snugly but loosely applied. 
They are intended simply to retain the splints in position (see 
Fig. 313). After their application, pressing the two splints to- 
gether should show that there is considerable slack in the straps 
{see Fig. 313) ; a spring should exist between the splints. The 
neces.sary pressure on the splints should be secured by the band- 
age. The fingers are allowed to be free and movable. The arm 
is held in a sling. The sling should be so adjusted as to receive 
the whole weight of the arm, the hand lying free from the up- 
ward pressure of the sling. The sling should be applied with 
the ends crossed in front of the neck. 



COLLES' FRACTURE TREATMENT 237 

At the end of the first week in most cases, in place of the two 
anteroposterior splints, it will be wise to use one posterior splint 
only and an anterior pad over the seat of fracture. The poste- 
rior splint is applied evenly padded, and if necessary, a small pad 
is placed over the dorsum of the lower fragment. The splint is 
held in place by two adhesive-plaster straps — one at the upper 
end of the splint around the forearm, the other around the meta- 
carpal bones at the lower end of the splint (sec Fig. 314). The 
fracture should be held securely by a third strip of adhesive 
plaster at the seat of fracture over a compress-cloth pad, which 
fills up the anterior hollow of the radius (see Fig, 3 1 5). This pad 
holds the fragments securely. A roller bandage gives even com- 
pression and support to the whole arm (see Fig. 316). 

The posterior surfaces of the forearm, wrist, and hand in the 
extended position are practically in one plane (see Fig. 317); 




hence, the reasonableness of the use of the posterior splint. The 
arm lies naturally upon it. The anterior surface only requires 
accurate padding. The difficulty in applying an anterior splint 
accurately to the forearm and wrist is rendered clear by the 
illustration. The front of the forearm and wrist is a rounded and 
uneven surface (see Fig. 317). In order accurately to control 
the bone by a splint applied to the anterior surface of the fore- 
arm, the padding must be applied with greater care than is ordi- 
narily exercised. No splint is manufactured that fits the wrist 
accurately. If the surgeon depends upon manufactured and 
molded splints, he is in very great danger of neglecting the frac- 
ture (sec Fig. 318). It is wiser for the surgeon to use simplc 
splints, and to hold the fracture reduced by personally applied 
' pads and straps. 



238 FRACTURES OF THE BONES OP THE FOREARM 

Until the time of union the arm should always be comforlabte. 
The patient should be seen, if convenient, within the first twenty- 
four hours of the application of the splint. Swelling may occiJr 
after the splints are applied, causing blueness or swelling of 
the fingers. The bandage may need reapplying to relieve this 
increase of pressure. With the subsidence of the primary 
swelling the bandage naturally loosens and will require tighten- 
ing. It is rare that the straps and padding will need more ihan 




slight readjustment during the first week of trfatment. At least 
every three days the pads should be removed with great care, 
and the arm carefully inspected. The alinement of the fragments 
is maintained by readjustment of the [Xids. 

Gentle massage should be instituted to the fingers, hand, 
wrist, and forearm during the second week. Passive and active 
movements of the fingers and wrist are to be made through 
the second week. During the second or third week it will be 



C0LLE5 FRACTURE TREATMENT 



239 



possible to shorten the dorsal splint and also to increase the 
amount of passive and active motion. At the end of the second 
or third week the union will be found to be firm. During the 




third or fourth week the splint may be removed and the wrist be 
supported by a wooden dorsal pad (see Figs. 319, 320) two inches 
long and the width of the wrist, and by a palmar radial pad of 
compress cloth and strips of adhesive plaster abont two inches 



240 FRACTURES OF THE BONES OF THE FOREARM 

wide. The middle of the plaster should come at the line 
of tlie break in the bone. After the fourth week all padding 
may be removed, and the wrist supported by a simple bandage. 
The fingers and hand may be used at this time. After the 
removal of the splint and while the arm is carried in a sling 
great care must be exercised lest lateral deformity result through 
an improper adjustment of the sling (see Fig. 321). The 
forearm should rest in the sling upon the ulnar side, and the 
hand, being unsupported, should be slightly adducted (see Fig. 
322). 

The treatment of a ** reversed Colles' " fracture (see Fig. 284) 
will differ from the treatment of the ordinary fracture only in the 
method of reduction and in the position of the retaining pads. 
An anterior (palmar) pad will be needed over the lower fragment 
and a posterior (dorsal) pad over the shaft of the radius. 

Prognosis and Result. — The swelling about the fracture in 
elderly people will persist longer than in the young. A func- 
tionally useful wrist-joint and hand should follow a simple un- 
complicated Colles' fracture in healthy young adults. For some 
weeks tenderness may exist over the styloid of the ulna. Limi- 
tation of pronation and supination may persist for some time, 
disap|Xiaring, after several months, more or less completely. 
Supination is the last movement to be recovered. Limitation of 
movement at the wrist .ind in the fingers is not incompatible with 
a useful wrist-joint. Bony union is rapid — within three weeks. 
Care must be exercised lest in the early removal of support the 
soft callus is molded, by the ordinary movements of the wrists 
and hand, into some permanent deformity. 

The destruction of puts of the lower fragment of the radius 
may have been so complete that it is impossible to restore the 
wrist to its normal shape, and some bony deformity will remain 
permanent!)' (sec X-ray plate, p. 230). Bony deformity is not 
incompatible with a functionalU' useful arm. In many instances 
it is impossible wholly to prevent a slunipinL^ forward of the 
lu\i(i of the ulna and its corres|)onding disappearance from the 
back of the wrist. Complete reduction of the radial deformit}' 
toj^ether with a frecjuently re-adjusted pad upon the palmar 
surface of the wrist over the slumpin^^ ulna-head are the best 



COLLES' FRACTURE PROGNOSIS 24 1 

methods for preventing the disappearance of the ulna from the 
dorsum of the wrist. Some sHght widening of the wrist will 
remain after most Colles' fractures. The changes in the tendon 
sheaths about the fracture, the periarticular adhesions that form, 
especially in elderly people, cause much more hindrance to 
recovery of function than do the bony alterations (see Fig. 323). 
Early and persistent massage and passive motion will prevent 
these changes from becoming permanently troublesome. Old 
people are liable to have considerable difficulty in regaining the 
movements of the fingers, on account of adhesions within and 
without the tendon sheaths. The continued use of the hot-air 
treatment is of value in restoring mobility to the wrist and 
fingers. 

Colles' fractures that have bony union with marked deformity 
should be corrected by osteotomy, if the wrist is functionally 
impaired. Colles' fractures two or three weeks old may be re- 
fractured manually, if necessary, to correct existing deformity. 
The ease of refracture and the limits in time within which it is 
possible will vary with individual cases. The more nearly the 
deformity in Colles' fracture is corrected, the milder will be the 
subsequent pain about the wrist. 



16 



CHAPTER XI 

FRACTURES OF THE CARPUS, METACARPUS, AND 
PHALANGES 

FRACTURE OF THE CARPUS 
Simple fracture of the carpal bones is unusual. It is as- 
sociated with other injuries. It is not uncommonly seen in 
crushes resulting in open fracture. The scaphoid is found frac- 
tured in certain Colles' fractures and in falls upon the out- 
stretched hand. There are many cases of painful wrist. •' rheu- 




matism " about the wrist, weak wrist, and sprained wrist that 
are instances of uiirecof;nizcd fracture of the scaphoid bone. 
The persistence of tiie difficulty necessitates a physician's exami- 
nation. In these cases a Rontgcn-ray cNamination will reveal 
the true nature of the lesion. After fracture of the scaphoid 
242 



FRACTUKE OF THE CARPUS 243 

bone persistent, painful limitation of extension at the wrist is not 
at ill! uncommon. The os magnum is sometimes fractured by 
falls upon the hand. 

Treatment. — If there is displacement, immediate pressure and 
counterpressure, associated with extension and flexion of the 




Fij. 3ii.—Cut 



Epiphyseal line. 



wrist-joint, under an anesthetic will usually reduce the displace- 
ment. Immobilization of the wrist-joint should be secured by 
means of a dorsal splint extending from above the middle of the 
forearm to the heads of the metacarpal bones (see Fig. 314). It 
should be retained by two adhesive -pi aster straps. Sheet wad- 



244 FRACTURES OF CARPUS, METACARPUS, AND PHALANGES 

ding and gauze roller bandages are then carefully applied to the 
arm the whole length of the splint {see Fig. 316). 

With the splint in position gentle massage to the wrist and 
forearm after the first week will hasten heaHng. Gentle passive 



Fije. ]i7.~Fracture of Ihc 








motion with more vigorous massage will be indicated at the end 
of two weeks. At the t-nd of three or four weeks all support 
save a roller bandage may be omitted. Stiffness will persist 
after this injury, e.^iwcially in elderly people (see I'igs. 324-328 
inclusive). 



FRACTURE OF THE METACARPAL BONES 
The third and fourth metacarpal bones are the ones most 
commonly broken. The fracture is due to a blow upon the 
knuckles (see Fig. 329). 

Symptoms. — The deformity is characteristic. The very con- 
siderable swelling often obscures the outline of the bones, but 
palpation detects the lower end of the upper fragment in the 
dorsum of the hand, while the upper end of the lower fragment 




Fig. 3».— Mcl*can"» ■"d phalanges 
loning Tpiphisu at fihccii ynn [Warnn 
[ui*um.s[Mcimens37). 




is sometimes felt in the palm of the hand (see Fig. 330). This 
deformity is characterized bya loss from the line of the knuckles 
of that knuckle corresponding to the fractured metacarpal (sec- 
Figs. 331, 332). Pain and crepitus are present. The hand can 
not be closed tightly on account of the swelling and pain. 

To obtain crepitus easily and to assist in reducing the fracture, 
it is best to grasp the finger corresponding to the fractured meta- 
carpal with the whole right hand, steadying the injured metacar- 
pus with the left hand, and then to make steady and continuous 
traction (see Fig. 333). The distal fragment is so short and 



246 FRACTURES OP CARPUS, METACARPUS, AND PHALANGES 

movable that unless this device is used to steady tlie fragment it 
will be difficult to determine crepitus and to reduce the fracture. 
This fracture heals readily. Occasionally, however, a suppurative 



^ iHP 



.at.! 




process may complicate recovery even when the fracture is not 
an open one. 

Treatment. — After reducing the fracture by traction and pres- 
sure as suggested, it must be held in place by special padding. 
for the deformity lends lo recur. The hand and forearm are 
supported upon a properly padded palmar splint. A pad is 



r 





^n 



J 




248 FRACTURES OF CARPUS, METACARPUS, AND PHALANGES 



placed in the palm over the prominent lower end of the meta- 
carpal. Another pad is placed upon the dorsum of the hand 




id connterprcuare by 






over the upper fragment. These pads are secured by narrow 
strips of adhesive plaster. The whole is then bandaged. If after 
carefully padding the two fragments and immobilizing them the 



TREATMENT 



249 



deformity is reproduced, the fragments slipping by each other, it 
may be necessary to make permanent traction upon the finger 
(see Fig. 334), This is best done by applying narrow adhesive- 
plaster straps to the sides of the finger held in place by circular 
and oblique straps. The hand rests upon the palmar splint. An 
adhesive-plaster circular band passed about the wrist and splint 
offers continuous countertraction. If the band is carried be- 
tween the thumb and forefinger, greater security is obtained, and 
there is much less likelihood of slipping of the plaster. The 





extension upon the finger is obtained by fastening the extension 
.strips to small pieces of rubber tubing, and carrying the tubing 
around a wooden peg or screw passed through a hole in the 
splint. 

A simple contrivance for a fracture with little displacement is 
the use of a roller bandage {.see Figs. 335-337 inclusive). A 
roller bandage of cotton cloth that is firm and not easily com- 
pressed and of a size comfortable for the hand to grasp is selected. 
This is placed in the palm of the extended hand ; the fingers and 
metacarpal heads are drawn down firmly over it. This po.sition 




IriRinei'ir could be fell in Ihc palm of Ihe hand ( lili&saehuiells General Hoaplul,"!^ 
X-ta>- iracing). 



PhaUnftcal epijihysla.- 
Noimtil epiphyseal liiK- 



-yy- 




TREATMENT ^51 

is maititamed by a broad strip of adiiesive plaster around the 
whole hand. Pads, as with the palmar splint, may be used to 
reinforce the roller bandage. Unless great care is exercised, this 
method will result in posterior bowing of the metacarpal bone. 
If there is an anterior displacement of either or both fragments, 
this roller-bandage apparatus is very efficient in maintaining re- 
duction of the deformity. 

This apparatus should be carefully inspected each day during 
the first week, to be sure that the position obtained is held firmly. 




After three weeks the splint may be omitted. Massage during 
the third week will be of benefit. Great care must be exercised 
in the use of the hand following the removal of the splint until 
the fourth week is passed, for deformity may result {see Figs. 
338-341 inclusive). 



FRACTURE OF THE PHALANGES 

The bones lie subcutaiicously ; fnictures of ihe phalanges are, 
accordingly, comparatively easy to delect. Fractures near the 



FRACTURE OF THE PHALANGES 



253 



articular surfaces are hard to detect because joint crepitus is 
deceptive. The so-called base-ball finger may, in many instances, 
be associated with a fracture of the head of the metacarpal bone, 
and, involving the joint, occasion a slow convalescence (see Fig. 
330). 

Symptoms. — Crepitus, pain, and abnormal mobility are pres- 
ent, and occasionally deformity is seen. 

Treatment. — It is important that the alinement of the phalan.\ 
be maintained. Rotation of the lower fragment upon its long 
axis is especially to be guarded against. Tcmjjorarily. if Uicre is 




much swelling, the broken finger may rest upon a palmar splint, 
the two adjoining fingers serving as lateral splints to steady it. 
The contiguous skin surfaces must be protected by strips of 
cotton cloth and a drying powder. 

A .single splint of thin wood, extending from the middle ol 
the palm of the hand to the finger-tip, and held in position by 
adhesive -plaster straps, is most useful (see P'ig. 343). The splint- 
wood used should be cut thin and not left thick and bungling — 
half the thickness of the wood of an ordinary cigar box is about 
right. The splint should be a little narrower than the finger itself. 
A narrow cotton bandage applied over the finger or a simple cot to 



2 54 FRACTURES OF CARPUS, METACARPUS, AND PHALANGES 

cover the finger will be comfortable and will assist in immobiliza- 
tion. Ordinary' letter-paper, by continued folding, may be made 
into a narrow and suitable splint. This is simple and efficient. 
It should be held in place by a bandage or, preferably, by a cot. 
Ordinary copper wire may be used, as shown in the illustration, 
without any padding (see Fig. 344). This serves as a proper 
protection after the first wxek or two, and is not so clumsy as 
other splints. The aluminium or tin finger splint is easily made 
and satisfactory' (see Fig. 345). Any displacement in this frac- 









c 



^ J. 

7 X j'/t 




ij?^ 



Fig. 348. — Thumb splint : a, Pattern — measurements are in inches ; d, position of splint. Note 

extension of thumb (after Goldthwaite). 



ture may be easily adjusted by narrow adhesive straps and small 
pads. 

Fractures of the first and second phalanges of the thumb may 
be satisfactorily treated after reduction upon a dorsal or lateral 
splint of wood, if proper padding is employed (see Figs. 346, 
347). Frequently, however, the tin splint fitted to the cleft 
between the thumb and forefinger, as shown in the illustration 
(Fig. 348), will immobilize these fractures more securely and 
comfortably. 

Open Fracture of the Phalanges. — This is usually followed 

by pr(^fuse suppuration from necrosis of the fractured bones. 
This fracture is to be treated with extreme care, especially 
as regards antisepsis. Immobilization should continue at least 



OPEN FRACTURE OF THE PHALANGES 255 

four weeks. If at the end of this time union has not occurred, 
the patient may be given the option of continuing the treatment 
or of having the finger amputated. If union does not occur after 
four weeks of careful treatment, it is highly improbable that it will 
ever occur. Resection of the bones may be attempted before 
amputation. 



CHAPTER XII 
FRACTURES OF THE FEMUR 

FRACTURE OF THE HIP OR NECK OF THE FEMUR 

Anatomy. — The crest of the ilium can be felt throughout its 
entire extent, from the anterior superior spine to the posterior 
superior spine. The posterior superior spine corresponds to the 
level of the center of the sacro-iliac synchondrosis. The great 
trochanter of the femur is easily distinguished even in fat indi- 
viduals. Nelaton's line is determined by stretching a tape from the 
anterior superior spine of the ilium to the tuberosity of the ischium 
(see Fig. 349). The top of the great trochanter lies at or a little 
below Nelaton's line, and about opposite to the symphysis pubis. 




FiK. 349- — Nelaton's line (dollecl line), from the anterior superior spine of the ilium to 
the tuberosity of ihe ischium. Bryant's triangle seen. Distance from lop of trochanter to 
perpendicular dropped from anterior spine (X) is Bryant's measurement. After fracture this 
measurement mav be less than normal. 



The internal condyle of the femur looks in the same general 
direction as the head and neck of the femur (see Figs. 350, 351). 
The anterior superior spine of the ilium is of importance because 
from it measurement is made in taking the length of the legs 
after fracture of the femur. Normally, the fingers can be hooked 
behind tlie great trochanter toward the posterior surface of the 
neck of the bone. By this manipulation the posterior portion of 
the capsule of the joint can be felt. 

Fracture of the Neck of the Femur in Adults. — This acci- 
dent occurs most frequently in elderly people. It ordinarily is 

256 



SYMPTOMS 



257 



associated with a very slight injury, such as a trip and fall upon 
the floor from the standing position. Undoubtedly, in many in- 
stances the fracture precedes the fall. It is often difficult to 
determine the exact seat of the lesion. Whether the fracture is 
within or without the capsule of the joint is of comparatively 
little moment. On the other hand, whether the fracture is im- 
pacted or unimpacted is of the greatest importance. Fractures 




\ 



/, 



F^K- 350- — Femur, from front. Note 
normal relation of direction of head and 
neck to that of internal condyle. 



.*%►' 



F'g- 35'- — Femur, from outer side. 
Note normal anterior bowine and relation 
of direction of head and neck to that of in- 
ternal condyle. 



of the base of the neck of the bone — that is, fractures near the 
trochanter — are usually impacted. Fractures of the neclc toward 
the head of the bone are usually unimpacted (sec Fig. 353). 
Impacted fractures unite readily. Unimpacted fractures often 
remain ununited. 

Symptoms. — The patient is unable to rise from the ground. 
A contusion may be seen over the hip as a result of the fall. 
17 



258 



FRACTURES OF THE FEMUR 



There is pain in the hip while the patient is lying still. This 
pain is increased upon motion at the hip. There is an inability 
to move the injured leg easily and painlessly. There is limita- 
tion of motion of the injured leg. While lying upon the back 
it is impossible for the patient to raise the heel from off the bed. 
The foot is everted, the leg having rolled outward. The whole 
extremity lies helpless (see Fig. 354). There is a slight appre- 
ciable fulhiess below the fold of the groin. This fullness in the 
outer upper part of Scarpa's triangle corresponds to a non- 
depressible area associated with fracture of the neck of the femur. 
Slight shortening of the leg exists. After three or four days 



(X^ 




FiK- 352.-- I'pper ciui of femur in u 
child: tf, </. Line of junciion of epiph>sis 
ol Iieaii iiiin shaft; ^.epiphysis of jijrealer 
Iroihanler ; r, epiphysis of lesser irochaii- 
Icr I Warren Museum, specimen 334). 




Fig. ^^}^' — Head and neck of femur of 
adull. The lines show the ordinary seats 
of fracluie. 



this shortening may increase to two inches. The trochanter is 
above Nclaton's line. The fascia above the trochanter is relaxed 
(see Mg. 355). This is especially noted in the standing position, 
with the patient restint; the weight upon the well leg. If the 
fracture is an impacted one. crepitus will be absent upon gentle 
manipulation, unless the imjKiction has been broken up by some 
unwise means. If the fracture is un impacted, crepitus can be 
detected 1)\' the hand while traction or gentle rotati(Mi of the leg 
is made. Tiie foot is everted whether impaction is present or 
not. If the imj)acli<>n is of the anterior portion of the neck, 
inversitui will i)e j)resent ; if the impaction is of the posterior 
portion of the neck. e\ersion will he pre'sent (see I'igs. 356, 357). 



FKACTUKE OF THE HIP EXAHrNATlON 259 

Impacted evcrsion can not be inverted nor can impacted inver- 
sion be everted without breaking up the impaction. In these 
cases of marked eversion and inversion a dislocation of ihe hip 
must be excluded if possible. 

Examination. — A prolonged search for crepitus and abnor- 
mal mobility must never be attempted. In order to avoid un- 
necessary movement of the hip and because inspection and gentle 
palpation alone will so often decide the diagnosis, it is wise to 
follow a routine examination. 

The history of the accident should be obtained. The pres- 
ence and location of pain are determined. How much is the 
functional usefulness of the lejj involved ? What does inspec- 
tion rL-veal as to the local condition and the position of the limb ? 




What docs palpation reveal ? How do the measurements of the 
leg and the trochanter compare with similar measurements ot 
the uninjured leg? I^st, — and to be avoided if a diagnosis has 
been reached, — what does gentle manipulation show as to the 
presence of crepitus in the hip ? 

In order to make a systematic examination all clothing, ol 
course, should be removed from the patient. He then should be 
placed upon a firm and even surface. A hard mattress, a table, 
or a comforter spread upon the floor will provide the necessary 
conditions. An anesthetic is hardly ever necessary for diag- 
nostic purpo.ses. If an anesthetic is employed, the hip should 
be handled in the gentlest manner possible. All muscular 
spasm, which without an anesthetic protected the hip from vio- 
lence, is abolished ; therefore, movements of the hip arc felt 



26o 



FRACTURES OF THE FEMUR 



directly by the bone unprotected by muscular spasm. All sud- 
den quick movements should be avoided. There is great danger 
that an impacted fracture of the hip may be changed by rough 
handling, especially in the movement of rotation, to an unim- 
pacted fracture. Palpation of the neck of the femur with the 
thumb in front of, and the fingers behind, the great trochanter 
will detect any irregularity or thickening and tenderness about 
the neck of the bone (see Fig. 365). By palpation of the great 




Fig. 355. — Relaxation of the fascia lata as a result of fracture of the hip. Most obvious at 

point shown by the arrow. 



trochanter one may discover there the seat of fracture. Swell- 
ing, tenderness, and crepitus maybe found. Only gentle strong 
traction in the line of the long axis of the thigh should be made 
to elicit crepitus and abnormal motion. 

Measurement. — The absence of any preexisting injury or dis- 
ease of the hip under consideration is always to be carefully 
noted. Measurement should always be made with the patient 
lying on the back. The le<j^ should be brought gently along- 
side of its fellow, and steadied by an assistant. Measurement 



- THE HIP MEASUKEMENT 



261 



should be made from the anterior superior spine of the ilium to 
the internal malleolus upon each side (see Fig. 385). If there is 
shortening upon the injured side, a fracture with some displace- 
ment is likely to have occurred. A normal difference in the 
length of the lower limbs is, however, not unusual. It is, there- 
fore, neces,sary to determine the presence of asymmetry if it exists, 
if any confidence is to be placed in the measurements of the legs. 
Measurements should, therefore, be made of the tibia; upon 




the two sides, and these compared. If no asymmetry appears 
to be present, any differences in measurement may be taken to be 
absolute. If it is impossible to bring the legs parallel, they 
must be placed in the same relative positions to the median line 
of the body. 

Bryant's method of measurement is simple and of .service (see 
Fig. 349). The limbs arc placed symmetrically. The top of the 
trochanter is marked upon the skin. A perpendicular line is 
dropped from the anterior superior spine to the table upon which 



262 



i OF THE FEMUR 



the patient lies. Measurement is made from tlie top of the 
trochanter to this perpendicular line. If fracture of tlie neck of 
the femur has occurred, and there is displacement or shortening 
of the limb, the distance from the perpendicular to the top of the 




trochanterivill he less than a like measurement on the uninjured 
side. The pusition of ihv top of tiic ■,'rcat trochanter is determined 
with reference to Nelaton's line (sec V\'^. 349), If the leg is 
-1IU1I outward, liislocatioii of the hip forwartl « ould be sus]>octC(l, 



FRACTURE OF THE HIP — MEASUREMENT 263 

but the absence of the head of the bone anteriorly and the 
absence of other positive signs should eliminate dislocation. If 
the leg is rolled inward, a dislocation of the hip upon the dorsum 
ilii would be considered. The absence of other positive signs of 
dislocation and the presence of the head of the bone in the acetab- 



Fig. 36i 
uotmpacled; Abi 
of the ii«k (W. 




uluni should convince one of the nonexistence of dislocation. 
In an elderly person who presents no well-marked sign of fracture, 
but wito is unable to use the Hmb after ever so slight an injury, 
a fracture of the hip should be so strongly suspected that, unlil 
the Rontgcn ray proves it absent, he should be treated as if a 
fracture were present. 



264 FRACTUKES OF THE FEMUK 

Prognosis and Result. — In the very aged and feeble the shock 
of a fracture of the neck of the femur is severe. The dan- 
ger to life in these cases is great. An elderly patient may die 
of shock within two or three days, or within a week of hypo- 
static pneumonia, or lie may live several weeks and die of 
exliau.stioii because of pain and the enforced confinement. If 
the fracture can be treated with proper immobilization, union will 
occur in most cases. The impacted cases will unite ; the unim- 
pacted cases may unite. Slight .shortening with a little deformity, 
some limitation in the movements of the hips, a limp, but a 
fairly useful limb, are to be hoped for (see Fig. 366). Chronic 
rheumatism will often prevent a fractured hip from ever becom- 
ing useful. 

Nonunion of the hip-fracture does not preclude a useful limb 




(see Fig. 367). Ununited fractures ot the hip are greatly bene- 
fited by proper ambulatory apparatus. They may be made to 
unite by mechanical means even several weeks and months after 
the injury. This is particularly true of fractures occurring in 
young adults. 

Results after Fracture of the Hip. — Of especial value in this 
connection are the conditions existing in sixteen cases of fracture 
of the hip, many years after the accident. The.se sixteen cases 
were treated at the Massachusetts General Hospital by gentle 
traction and immobilization, for periods varying from a few weeks 
to a few months. The patients then went about with crutches. 
No other treatment was used. Nearly all the cases were unim- 
pacted cither primarily or .secondarily. At the time of the acci- 
dent seven cases were between forty-two and forty-seven years 



FRACTURE OF THE HIP PROGNOSIS 265 

old, the remainder — with two exceptions, whose ages are not 
stated — were over fifty ; three were over sixty years old. These 
cases reported for examination from two and one-half to twenty- 
four and one-half years after the accident. Thirteen of the six- 
teen cases have impairment of the functional usefulness of the 
leg ; a weakness of the limb, necessitating a crutch in many in- 
stances ; all movements at the hip somewhat restricted ; atrophy 
of the muscles of the thigh, buttock, and calf of the leg ; a de- 
cided limp, requiring a cane , pain in the hip extending down the 




I. 3M.— Dcformily fu11< 




Union liramenlouM. 
Useful lirrib iX-ray In 



thigh even to the sole ot the foot ; pain at night in the hip ; 
pain In going up-stairs and in stooping over. In only two cases 
out of the sixteen could it be said that the leg was functionally 
useful. 

Treatment. — Central Considerations. — Fractures of the hip or 
of the neck of the femur demand the greatest tact in their man- 
agement. The aged respond readily to care. The patient should 
be made to feel as comfortable as possible wliile confined to his 
bed. Particular attention should be paid to diet and to all little 



266 



FRACTURES OF THE FEMUR 



comforts. The discomforts attendant upon immobilization are 
often very great. Let the days spent in bed be made especially 
attractive. Be sure that agreeable friends visit the patient, see- 
ing to it that they do not stay so long a time as to weary him. 
Let them interest him in the news of the day, so that he may 
feel that he is keeping up with events. Employ a skilled 
nurse to minister to his wants : a bright and cheerful woman 







^'ig- 368.— Case : Fracture of the neck of the femur (X-ray tracing). 



nurse is ordinarily better than a man nurse. The pulse is to be 
carefully watched as well as the respiration. A moderate amount 
of alcolu^l once or twice a dav with meals is to be used. The 
courage of the ai^cd needs bracing. Bed-sores develop with 
surprising rapidit)'. Skilled watchfulness and immediate treat- 
ment will often check the progress of a red pressure spot. The 
p. lit exposed to piessure should be kept \er\' clean with soap 
and u.utn water ; it sliould be bathed with alcohol, thoroughly 



FRACTURE OF THE HIP TREATMENT 267 

dried, and well dusted with powder (starch and oxid of zinc, 
equal parts) ; and the pressure should be relieved by proper pads 
or cushions. If the heel is the part involved, a rubber cushion 
or a ring made of sheet wadding wound with a bandage may 
be used. A certain amount of moving about in bed should 
be granted to old people. Asthenic hypostatic pneumonia 
from long-continued resting in one position is not uncom- 
mon. Therefore, moving about a little in bed, to the extent of 
sitting upon a bed-rest at varying angles, is beneficial. Deep 
rhythmical breathing while lying flat on the back is a splendid 
stimulator of the circulation. In the case of a fracture of the 
neck of the thigh-bone occurring in an elderly individual treat the 
patient and let the fracture be of almost secondary importance. 

Treatment of the Fractured Hip. — The patient should be 
placed upon a comfortable, firm, hair mattress. Underneath the 
mattress, crossing the bedstead from side to side, should be 
placed several wooden slats about eight inches apart. These 
bed-slats prevent sagging of the mattress and much consequent 
discomfort. Great caution must be exercised that no sudden or 
forcible movements of the hip are made which might break up 
the impaction of the bone or cause unnecessary pain. The leg 
should be placed in as natural a position in extension as possible. 
The knee should be placed upon a pillow. Extension strips of 
adhesive plaster should be applied to the leg and thigh as high 
as the perineum, and should be held to the skin by a gauze roller 
bandage. A weight of about five pounds should be applied to 
the extension while the leg is gently rotated and carefully placed 
approximately in the normal position. The foot of the bed 
should be elevated to the height of six inches in order to secure 
counterextension. Long and heavy sand-bags should be placed 
on each side of the leg and thigh to assist the light extension 
in affording support and to give a sense of security. The heel, 
as mentioned before, should be properly protected from undue 
pressure. The foot should be kept at a right angle with the 
leg. To afford still greater immobilization, a long T-splint ex- 
tending from below the foot to the axilla of the injured side may 
be applied by straps about the leg and a swathe about the body 
(see Fig. 398). 



268 FRACTURES OF THE FEMUR 

After-care of the Simple Traction Method, — The general care 
of the patient should be as outlined previously. He should be 
kept quiet in bed for about two weeks. During the second week 
he may be bolstered up on pillows to the half-sitting position. 
Ordinarily, the extension may be removed during the third 
week. The patient may then be lifted to another bed or divan 
and be rolled into an adjoining room. In this change the thigh 
should be supported by sand-bags. The patient may be up in a 
wheel-chair after the first six weeks or two months with the knee 
straight on a board or, if comfortable, flexed. He may use 
crutches and a high shoe upon the well foot, not bearing any 
weight upon the injured hip, after about two months or ten 
weeks. He should not bear weight upon the hip even with the 
assistance of crutches for about three or four months. At the 
end of a year he may be walking with one cane. The foregoing 
is the course of an ideal case treated according to the old-time 
simple extension or partial immobilization method. It is a 
matter of common observation that many impacted hips recover 
with fairly useful limbs with this treatment. Impacted hips are 
known to have recovered with useful limbs without any medical 
or suri^ical advice or treatment, the impacted fracture having 
been thought at the time of the injury to be a severe contusion 
which would be all right in time. These cases have occurred 
both among adults and children. 

Greater immobilization of the impacted and unimpacted hip is 
demanded in most cases than can be obtained by the simple 
traction and countertraction previously described. The simple 
method is far from ideal : mal union and nonunion with resulting 
disability too often follow its use, the period of disability is long, 
and the ultimate results arc often most unsatisfactory. Very 
refractory individuals will have to be loft pretty much to them- 
selves. No great restraint can to advantage be forced upon 
them. 

TJic Fixixtio)i MitJiod of Iridtmcfit. — In order to put the unim- 
pactcd bones of the hi})-joint under the \'ery best conditions for 
union to take place not only must the frat^nunts he approximated 
by traction, correction of eversion or inversi(.)n, and lateral pres- 
sure over the trochanter major, but these fragments must be 



FRACTUHE OF THE HIP TREATMENT 269 

firmly fixed. In order to immobilize these fragments absolutely 
the body or pelvis and the thigh must be fixed. The simple 
method already described, In spite of the fact that it has been 
used for many years in these cases, does not immobilize. The 
most comfortable and efficient method of immobilization is by 
the use of the Thomas hip-splint. The description which follows 
of the Thomas hip-splint and its use is that given by Ridion. 

The Thomas hip-splint secures posterior support to the frac- 
ture, gives fixation without compression of the fractured region 




honiM' sinile hi 
«ilion (Ridloii). 



except posteriorly, allows the patient to be lilted with case, does 
not interfere with the groin, favors cleanliness, admits of traction. 
can be applied without moving the patient and without assist- 
ance, and pre-sent-i no difficulties after the initial application (see 
Figs. 369. 3;o)- 

The splint is made of soft iron, and consists of a main stem, a 
chest-band, a tliigh-b;md, and a calf-band, flu stem is an inch 
and a quarter wide and one-fourth of an inch thick, and in length 
reaches from the axilla to the calf of the leg — the length of the 
lower portion from ihc hip-joint to the calf of the leg being eqnal 



270 FRACTURES OF THE FEMUR 

to that from the axilla to the hip-joint. In the part opposite the 
buttock two gentle bends are made, the lower somewhat back- 
ward and the upper upward, so that the body and leg portions 
of the splint follow parallel lines from one-half to one inch apart, 
the body portion being posterior to the leg portion. The stouter 
the patient, the more nearly do these parallel lines coincide, and 
in some cases the main stem may be left entirely straight. To 
the lower end is fastened, by one rivet, the calf-band, one-six- 
teenth by five-eighths of an inch, and in length an inch or two 
less than the circumference of the leg at this point. The thigh- 
hand is one-sixteenth by three-fourths of an inch, and in length 
an inch or two less than the circumference of the thigh at its 
largest part ; it is riveted to the main stem just below the lower 
bend, so that when applied to the patient, it comes well up to 
the perineum. The chest-band is three-thirty-seconds by one and 
one-fourth inches, and in length nearly equal to the circumfer- 
ence of the chest, being relatively longer than the other bands. 
It is fastened by one rivet after the upper end of the stem has 
been forged flat and bent back over it. This arrangement makes 
a fast joint, and brings the stem between the chest-band and the 
skin. /// eacJi end of the chest-band a round hole is forged of at 
least one-half of an inch in diameter. 

Summary of material and measurements required in making 
the Thomas splint : 

Stem, I V^ inches wide, V^ inch thick, extending from the 
axilla to the calf of the leg. 

Calf -band, ^^ inch wide, ^^ inch thick ; the length is two 
inches less than the circumference of the calf of the leg. 

Thigh-band, j\ inch wide, ^^ inch thick ; the length is two 
inches less than the largest circumference of the thigh. 

Cliest-band, i \^ inches wide, .^'V inch thick ; the length to 
nearly equal the circumference of the chest. 

A liolt is forced at each end of the chest-band, V-* inch in 
diameter. An\' good blacksmith can make this splint in a very 
short time. 

The splint is now bent to fit approximately the patient, padded 
on the side that is to come next the skin with a c[uarter-inch 
thickness of felt, care bciii<^ taken to lea\e no inequalities of sur- 



FRACTURE OF THE HIP TREATMENT 27 I 

face, and then covered with basil leather put on wet and tightly 
drawn, so that when dry it will have shrunk sufficiently to pre- 
vent the cover from slipping on the iron. The splint is applied 
by opening out the wings of the bands looking to the uninjured 
side of the patient, and then slipping them, followed by the 
stem, underneath the patient from the injured side ; the wings 
that were straightened are bent again by hand and readily return 
to their former curves. A closer and more accurate adjustment 
of the wings may be made by the use of wrenches ; these will 
be found especially serviceable in fitting the chest-band and in 
drawing in the other bands when the patient is very intolerant 
of any threatened movement or jarring. 

** The splint having been fitted, if retentive traction is not 
required, the limb is bandaged to the stem from the calf to the 
upper part of the thigh, rolling the bandage in the direction the 
opposite to the rotary deformity that may be present ; then 
shoulder-straps are applied by taking a couple of yards of broad 
bandage or a strip of muslin, looping it round the stem where it 
joins the chest-band, then over the band and over the shoulders, 
and down to the ends of the chest-band. Here it is passed 
through the holes and tied ; then it is passed across the interven- 
ing space to the opposite hole and again tied. If retentive trac- 
tion is desired, the shoulder-straps are omitted. To each side of 
the limb from the upper part of the thigh after the limb has been 
pulled down to the splint a broad strip of adhesive plaster is 
applied. The lower ends of the plaster are turned outward and 
upward around the wings of the calf-band, where they are fas- 
tened by a strip of plaster passed entirely around the limb ; the 
whole is then covered with a bandage. By this arrangement the 
limb is pulled upon only to the extent of correcting the actual 
shortening, and is held at one and the same length sleeping or 
waking, whether the muscles relapse or are spasmodically con- 
tracted. 

*'The device aims to prevent motion in the axis of the limb ; 
to prevent lateral motion by bending the limb in any direction ; 
to do this without constricting the region of the fracture ; and to 
enable the patient to have the bed-pan adjusted without pain and 
without disturbing the relation of the parts. When the splint 



273 



FRACTURES OF THE FEMUR 



has been applied and the patient is in bed, the nurse should be 
instructed in certain mantcuvers. The bed-pan is adjusted by 
passing the arm under both limbs or below the knees and then 
lifting directly upward, making an incline of the whole patient 
below the chest-band. By this manceuver it is also more easy 
to smoothe out wrinkles in the bedding and change the sheet 
than in the usual way. The stem should be made to press upon 




diflerent parts of the skin by pulling the skin night and morning 
first to iKie side and then to the other. The [latient should be 
inspected daily for prcsiiirc sores by turning him on the sound 
side. In orderto (urn a patient upon the sound side support the 
fracturcil limb at tlic knee with one hand and gras]) the chest- 
band with the other ; the patient then is readily turned as a whole. 
Tlie points nio.st likely to suffer from pressure are lliose at the 



FRACTURE OF THE HIP TREATMENT 273 

junction of the thigh-band and stem, the lower bend of the stem, 
and the junction of the stem and chest-band. Points pressed 
upon should be lightly dressed with flexible collodion and pro- 
tected from further pressure by padding above and below. If 
the pressure of the whole body portion of the stem is complained 
of, a small, thin mattress of hair or a sheet folded to several 
thicknesses may be. placed between the splint and the patient's 
back. Threatened hypostatic congestion is obviated by raising 
the head of the bed from one to three feet, the patient meanwhile 
being prevented from slipping down by tying the splint to the 
head of the bed. In all cases obviously unimpactcd and in all 




Fi^- 37'- — Skiagram tracing of patient two and a half years of age, after the accident, 
illustrating the detormity of the neck and of the upper extremity ot the shaft, also the eleva- 
tion of the pelvis on the affected side (after Whitman). 



cases when the shortening is more than three-fourths of an inch, 
traction should be applied. 

" In all cases the splint should be kept on for from six to eight 
weeks after all pain has ceased ; then the patient .should remain 
in bed four weeks longer without any treatment whatever, unless 
there is some positive indication to the contrar>', in which case 
the splint is cut off at the knee and the calf-band riveted at this 
point and the patient permitted to go about with crutches." 

In addition to the use of the Thomas splint, it may be wise to 

make lateral pressure, as suggested by Senn,over the trochanter 

of the broken hip with the expectation of more firmly fixing the 

broken bone. Lateral pressure may be secured by a surcingle 

or by a bandage applied over a graduated compress. The spot 
18 



274 



FRACTURES OF THE FEMUR 



to which pressure is applied should be carefully watched and 
protected. 

The Operative Treatment, — Suturing or pegging the fragment 
is very properly to be reserved for fractures occurring in young 
adults in whom the absolute fixation by the Thomas splint for a 
reasonable period has not affected union. 




Fig. ;>7.^ -TraciiiK <>f photograph of patient eight years oUI, some years after a fracture 
of the neck of ilie riglit femur, showing great projection ami elevation of the trochanter, 
made more apparent h\ flexing the thigh atui leg iVVhitman). 



Fracture of the Neck of the Femur in Childhood. — Whit- 
man has called especial attention to this fracture. The anatom- 
ical proof of the existence of fracture of the neck of the femur in 
childhood has betMi furnished by the specimens of Bolton, Meyers, 
and Starr. The fracture occurs after traumatism to the hip prob- 



2/6 FRACTURES OF THE FEMUR 

ably more frequently than separation of the upper femoral epiphy- 
sis. It is not so uncommon an accident as has been supposed. 
The fracture is probably impacted or grecnstick. The clinical 
picture of fracture of the neck of the femur in childhood differs 
jrreatly from that furnished by a similar injury in old age. In 
the first instance a healthy child falls from a height, and presents 
a shortening of the thigh of from y^ to 3.4 of an inch. There 
are slight outward rotation of the leg and limitation of motion and 
slight discomfort in the hip. The child may walk about after 
a few days with but a little lameness to suggest that any injury 
has been received. The child recovers with a limp. Months 
or years later signs of coxa vara appear. In childhood a rather 
severe injury is followed by immediate symptoms, and later 
by great disability. On the other hand, in old age a trivial 
injury is followed by immediate and complete disability. It is 
often overlooked in the child and is treated for a contusion or 
sprain of the hip. The immediate result, however, is extremely 
good even without more than bed treatment, but the ultimate 
result after sev^cral months or years may be disastrous because 
of the disability due to a gradually increasing bending of the 
femoral nock. The late result of fracture of the femoral neck in 
childhood resembles hip-disease in the limp, slight pain, short- 
ening, deformity, and limitation of motion present. Care must 
be taken not to confound the two conditions. These later stages 
of fracture arc to be treated by rest to the joint. All body- 
weight and the jar of walking are to be removed by a properly 
fitting hip-splint with traction. Refracture and operative meas- 
ures are to be seriously entertained, as in other forms of coxa 
vara, particularly if the disability is great or is increasing (see 

^^^'^^' 17^-1)7^ inclusive). 

The treatment of a fresh grecnstick or impacted fracture of 
the hip in children should be by rest on the back in bed 
and moderate traction and immobilization of the hip and 
thigh and hod)'. After a month the child may be allowed up. 
wearing a traction hip-splint for several months until union is so 
firm that tlu- daiv'cr from coxa \ara is practicalh' eliminated. A 
light plastcr-of- Paris spica bandage from calf to axilla will main- 
tain immobility aftrr the splint is omitted. 



370 FRACTURES OF THE FEMUR 

FRACTURE OF THE SHAFT OF THE FEMUR 

Fracture of the shaft oi the femur is usuallj' cibliquc. It is 
situated either just below the lesser trochanter (subtrochanteric 
fracture), at the center of the shaft, or above the condyles 
(supracondyloid fracture). Even in closed fractures there is 
sometimes great damage to the soft parts : the vessels of the 
tiiigh are at times injured. 

Symptoms. — There is often great swelling at the seat of 
fracture. The limb lies helpless. Pain, abnormal mobility, 
deformity, marked lateral rolling of the leg below the seat of the 




.for-Blly. 



fracture, and crepitus, one or all, may be evident (see Figs. 
i79- 3^0)' The limb is shortened. 

Measurement {see Figs. 3S3— 386 inclusive) to determine the 
amount of the shortening is to be made from the anterior superior 
spinous process of the ilium to the internal malleolus of the .same 
side. Great care must be exercised in taking this measurement 
so that the patient lies flat upon the back upon a hard and even 
surface, with the arms at the sides of the body and with no pillow 
under the head or shoulders. The long axis of the body should 
be in the same line with the long axis between the legs as they 
lie with the malleoli approximated — /. i.. the chin, cpisternal 
notch, umbilicus, the symphysis pubis, the midpoint between the 
knees, and the midpoint between the internal malleoli should all 



i. 



THE SHAFT OF THE FEMUH 2^9 

be in one straight line (see Fig. 386). The line joining the anlo- 
rior superior spinous processes of the iiia should be at right angles 
to this long axis of the body and thighs. Any variations from 
thiy normal position are attended by errors in measurement, 
which are important. If for any reason the injured thigh can not 
be brought easily alongside its fellow, the two limbs should be 
placed as nearly symmetrical with reference to the median line 
as possible. 

The method of measuring the lengths of the lower extremities 
used by Dr. Keen differs from the above in that he uses the 
malleolus as the fixed point, and measures to a line drawn at the 




anterior superior spinous process of the ilium. The finger and 
tape are not allowed to touch the skin-mark, and so do not dis- 
place it. 

Treatment of Fracture of the Shaft of the Femur. — The 
Transportation of a Patient : The emergency method of put- 
ting up a fracture of the thigh or hip is of very great practical 
importance (see Fig. 3S7). Limbs are fractured frequently some 
distance from the proper place for the application of the perma- 
nent dressing, It is necessary to transport such cases with the 
greatest degree of safely and comfort. In order to accomplish 
this the knee- and hip-joints should be extended, the leg being 







Fig. 381.— Fiaciurc oF II e uppcrihiril ol llie afasli of the ciRhl fcmiic (X-ny traciiijt). 




Till-: SHAFT OF THE FtML'K 30 1 

held straigliteiied in tlie loii«r axis of llie body. The limb 
should be placed upon a licavily padded board, the width of 
the thigh, extending from the middle of the calf to above 
the sacrum. The side splints of wood should be used — one 
on the outer side LXtending from the side of the foot to the 
axilla, the other upon tlie inner side extending from the side 




of the fool to a kw inches below the perineum. Upon the 
front of the thigh is phiced a co;iptalion splint e.Ntending 
from the groin to the patella. All of these splints are care- 
fully padded, preferably with folded sheets or pillow-cases or 
towels ; of course, in emergency work small pillows or coats or 
shawls may be utilized. It is important thai the padding be 



I 



252 I'RACTURES OV THE FEMUR 

evenly and intelligently arranged. It will be necessary to place 
a wide pad between the upper end of the long outside splint, to 
prevent it from pressing upon the ribs and side of the chest and 
causing {:;reat discomfort. These splints are held in position 
about the leg, while gentle traction is being made upon the 
limb by straps or pieces of bandage placed above the ankle, 
below the knee, above the knee, at the middle of the thigh, 
and at the level of the perineum. The upper end of the 



D 



t-i«. 3»S.— Mesiureiiitiiloflowereiilrtimly. Puiiti.l vinRo,. iliehsck looted airromalmvi. 

long outside .splint is held to the side by a swathe about 
the body and splint. The patient should then be carefully 
placed upon a stretcher {a Bradford frame is an ideal form of 
stretcher) improvised for the occasion. With this apparatus 
snugly applied, the patient may be securely and comfortably 
transported. 

The objects of treatment arc to reduce the fracture, to main- 
tain the reduction immobilized until union is firm, and to restore 



THE SHAFT OF THE FEMUR 283 

the leg to its normal usefulness. In the treatment of two of the 
three varieties of fracture of the femur permanent traction upon 
the lower fragment and permanent countertraction upon the 
upper fragment are necessary. 




Fie. ,)S6.— Mcasurcmcnl of the length o( Ihs lower cwremity. Pllicnl nprcHi 
on back, looked Bt from above. TheW jninine the atxerior luperior spinoui pr 



(Drawn by C. Rim 






The patient with a fractured thigh should always be anesthe- 
tized before putting the thigh up permanently. Never anesthetize 
the patient until all the different parts of the apparatus are ready 
and on a table near the bed of the patient. Always put the 
thigh up in temporary dressings until all is prepared for the per- 



2S4 FRACTUHES OK THE VEMUB 

maiient splints. About one hour will be consumed in applying the 
extension apparatus after the patient is anesthetized. There will 
be no harm in letting the patient rest comfortably in the tempo- 
rary splints over one night until all necessar>- arrangements have 
been made for the permanent dressing. 

Method of Examination : The patient is completely anesthe- 
tized in order to secure muscular relaxation. Accurate examina- 
tion is now made of the fracture. If the ends of the fragments lie 
clo-;e to the skin, great care must be exercised, by steadying the 




THE SHAKr OF THE FEMUK 285 

In adults in fracture of the middle of the shaft of tlic fcniur 
traction and immobilization are best maintained by a modified 
Buck's extension apparatus. Materials needed for a modified 
Buck's extension : Two strips of adhesive plasttr, each two 
inches wide and long enough to extend from the seat of fr.icture 
to the internal malleolus. Surgeon's adhesive plaster is nonirri- 
tating to the skin, and is prepared in rolls of convenient width. 
To each strip of plaster at the ankle end should be stitched a 
piece of webbing the width of the plaster and about six inches 



«.389.-Pii1leyiiniinBedo 




long. Prepare five other strips of adhesive plaster, all of which 
should be one and a half inches wide. Three of these strips 
should be long enough to encircle respectively the leg above the 
malleoli, the knee above the condyles, and the thigh an inch 
below the seat of the fracture. The remaining two strips oi 
plaster should be long enough to extend spirally from the mal- 
leoli around the leg and thigh to the seat of fracture. Prepare 
also a roller bandage of gauze or cotton cloth, a curved or straight 
haiH-spliiit properly padded, and three adhesive .straps for hold- 
ing the ham-splint. 



THE SHAFT OF THE FEMUK 387 

In addition, three coaptation splints for surrounding the thigh 
are required, also six webbing straps with buckles or strips of 
bandage to \x, used as straps ; fresh sheets or pillow-cases or 
towels for padding; a swathe, to encircle the pelvis,- made of 
unbleached cotton cloth or mediirm weight Shaker flannel ; and 
3i\o(\g outside splint of ivood, (our inches wide, to extend from 
the axilla to six inches below the sole of the foot. To this last 
a cross-piece, eightec'n inches long, should be fastened, making 
thus a long T-splint. The list is completed by two to^iels for 
perineal straps, safety-pins, a pulley, which can be bought at little 
cost at any hardware store (see Fig, 389). This pulley should 
be screwed into a brooiu-liaiuilc cut to the right height. A block 




with hooks above and a pulley below will sometimes be found to 
be more convenient than the broom-handle arrangement (see 
Fig. 391). A spreader (see Fig. 392), which is a piece of wood 
two inches wide and a little longer than the width of the foot, 
perforated at its center for the extension weight cord. Tl»cre 
should be provided a cord, three feet long, size of a clothes-line ; 
two bricks or wooden blocks for elevating tlie foot of the bed ; 
four sand-dags, twenty inches long and .six inches wide ; a cradle 
(see Figs. 393, 394) to keep the weight of the clothes from the 
thigh — the cradle may be a chair tipped up, or barrel-hoops 
nailed toj,'ether. 

Application of the Modified Buck's Extension. — Ail the 
materials being in readiness and at hand, the patient having been 



388 FRACTUKES OF THE FEMUR 

etherized and tlie fracture examined, the thigh and leg and foot 
are first washed witli warm water and Castile soap and thor- 
oughly dried. Tiic long straight strips of adhesive plaster with 
the webbing attached are applied to the middle of the two sides 
of the leg and thigh up to the seat of fracture. The junction of 
the adhesive plaster and webbing should be brought to just 
above the malleoli. The two spiral and then the three circular 
strips should next be applied as indicated (sec Fig. 395). Over 
the extension is placed a roller bandage, snugly and evenly 




hufiiiB ankle BiiU fool 



inclo.sing the font. The bandiige steadies the adhesive plaster, 
pruvcnis swelling of the foot, and affords comfort. Then the 
paildcd posterior coaptation or ham-.spUnt is applied and held by 
three slra]>s of adhesive plaster, one at each end of the splint 
and one helnw the knee (see I-'ig. 396). If the cnrved hani-splinl 
is used, the |>;iddiii5j (one sheet of sheet wadding) should be laid 
upon the splint eveidy Ihrniigh.jiit. If a stniight ham-splint is 
used, the jadding should he applied evenly, and at the middle of 
the ham, behind the knee, ^IiovlM he placed an additional pad (see 
I'ii;. v^D in order to support the knee in its natural position. 



THE SHAFT OF THE FEMUR 



289 



This additional pad should be placed between the splint and the 
layer of sheet wadding. The tendency of the padding of the 
ham-splint is to shp away from each end of the splint and thus 
leave it unduly pressing into the thigh and calf. It is wise to 
hold this padding in place by strips of adhesive plaster at each 
end of the splint. The three thigh coaptation splints should be 
next put in position — one anteriorly, extending the whole length 




F'K' 393* — Cradle lo keep clothes from leg. Made from two barrel-hoops. 




Fig:. 394* — Cradle to keep clothes from leg. Made from two barrel-hoops. 



of the thigh from groin to patella ; one externally, extending 
from trochanter to external condyle ; and one internally, extend- 
ing from just below the perineum to just above the adductor 
tubercle (see Fig. 397). The best padding for these splints is 
a towel folded the length of the splints and placed evenly about 
the thigh. These splints are held by an assistant while three or 
four straps are tightened sufficiently to hold them firmly in place. 
While the.se coaptation splints are being applied it is very impor- 
"9 



tant that steady traction be made upon the tower fragment in 
order to maintain its reduction. The siraps of tJie coaptation 
splints arc then finally tightened. The long outside splint with 
the T cross-piece is then padded with sheets and applied to the 
side of the limb and the body (see Fig. 398). The upper end of 
the splint is inclosed in a swathe, which passes around the body 
and is fastened with safety-pins. The tiiigh and leg are held 




iglr apfliec 



steadily to the outside splint by two or three straps (sec Fig. 
399). The assistant, making extension, exchanges his traction 
for that of the weight and pulley. The foot of the bed is raised 
upon blocks or bricks, in order to provide the counterextcnsion 
by means of the weight of the body, The heel is protected from 
undue pressure by a ring. The foot is kept at a right angle with 
the leg (see Figs. 400, 401). The sand-bags are laid along the 



292 FRACTURES OF THE FEMUR 

inner and outer sides of the limb to add greater steadiness to the 
apparatus. The cradle is placed over the foot and leg. 

Throughout the course of the treatment of a fracture of the 




THE SHAFT OF THE FEMUR 



293 



thigh it is necessary to be positive of four things ; (a) The 
absence of shortening in the injured thigh ; (d) the prevention of 
outward bowing of the thigh ; (<r) the prevention of permanent 
rotation of the leg and lower thigh outward below the seat of 
fracture ; and finally (d), the 
prevention of a sagging back- 
ward of the thigh at the seat 
of fracture, causing what ap- 
pears on standing as a false 
genu recurvatum, 

(a) The shortening of the 
injured leg is prevented by a 
sufficiently heavy weight for 
extension. This weight can 
be approximately but not ac- 
curately determined. Ordin- 
arily, in an adult fifteen or 
twenty pounds are needed to 
hold the fragments in proper 
position. Comparative meas- 
urement of the legs from an- 
terior superior spinous pro- 
cess to the malleolus should 
be made regularly every other 
day, and the measurements 
recorded during the first two 
weeks of immobilization and 
the extension weight corre- 
spondingly adjusted. 

((*) In order to prevent any 
outward bowing of the thigh, 
the thigh and leg should be 
slightly abducted after the 
apparatus is applied, so that the extension is made with the limb 
in this abducted position (see Kig. 404}. 

(f) In order to prevent the thigh from rotating outward below 
the fracture and thus carrying the leg and foot with it, — to pre- 
vent, in other words, eversion of the foot, — a bandage six inches 








294 FKACTURES OF THE FKMUK 

wide should be fastened by pins below the calf of the leg to the 
posterior part of the bandage or ham-splint, and brought up on 
the outer side of the leg and fastened to the long outside splint 
or to the cradle above. The leg meanwhile is held in the cor- 




.11 of'lhelliopHMl .-- . 



reeled position. If this bandage is fastened to the cradle, the 
latter should be fastened firmly to the bed. 

(,/) The sagging backward of the thigh (see Fig. 403) is 
prevented by the posterior coaptati()n splint and its proper pad- 
ding. (See Siipracondyloid Fracture of the Femur.) 



SUBTROCHANTERIC FRACTURE 



^95 



Subtrochanteric Fracture of the Shaft of the Femur. — 

Fractures of the upper third of tlie shaft are comijaratively 
rare. The diagnosis of this fracture is not ordinarily difficult. 
The displacement is characteristic : The upper fragment is flexed 
and abducted, and the lower fragment overrides the upper one 
and is sliglitly adducted. Tlie treatment should restore the line 
of the thigh. At times the ordinary extension and counterex- 
tension, as for a fracture of the middle of the femur, may prove 





effective. If it is not effective, — and it usually is not, — the leg 
and lower fragment should be elevated upon an inclined plane 
(see Fig. 422), so as to bring the lower fragment up to the upper 
one, for it will be found impossible to lower the upper fragment 
Traction should then be made in the line of the elevated thigh 
from above the condyles of the femur. If position and traction 
are ineflficient, — and they usually are, — then suturing of the 
fragments should be contemplated. 

It will be found impossible to correct completely the ordinary 



296 FRACTURES OF THE FEMUR 

deformity of abduction and flexion of the upper fragment and 
adduction and riding up of the lower fragment by traction upon 
the lower fragment, no matter in what position the lower frag- 
ment may be placed for traction. Rendering the closed fracture 
opeu by incision and suturing the bones in position is the only 
possible way of securing a perfect result either anatomically or 
functionally. The surgeon must be judicious in the selection of 
the patients upon whom he operates. Even though old, if the 




patient is in oxcoUcnt general health, the operation may be done 
with every prospect of siiccess. 

Supracondyloid Fracture of the Femur, — The deformity is 

char.icteristic and r:iirly typical Iscc Kigs. 414, 41 5) ; displacement 
of bnih fragments backwiuil is s<imctimcs seen (see l*"ig. 420). 
Tile upper end iif the lower fragment is dis])[aced backward. 
ehielly tiinnigh the i»iill upon il by the giistrocnemiu.s muscle. 

Tre:anienl of this fracture in the straight and extended posi- 
tion is iisiiailv un.salisfactory. It is iiecessary cither to flex the 
Ic' in order In relax the g.istrocnetniiLs muscle or to do a ten- 



SUPHACONDVLOID FRACTL'KE 



297 



otomy upon the tendo Achillis. One of these procedures having 
been carried out, the thigh and leg should then be placed upon 
a double inclined plane (see Fig. 422). Pressure by pads may 
be exerted upon the upper end of tiie lower fragment in order to 
lift it forward into apposition witli the upper fragment. Slight 
traction, if possible, should be maintained upon the lower frag- 
ment. Ref>eated examinations with the fluoroscope will indicate 
when reduction is completed. 

The After-treatment and Progress of Fracture of the 
Thigh. — Inspection of the fractured limb should be made at 




least daily. Measurement should be made twice a week during 
the first few weeks, the internal malleolus being reached through 
the bandage. Parts of the apparatus may need changing, and 
straps may require tightening or loosening. The heel and sacrum 
will require attention because of the constant pressure from lying 
in one position. 

Ordinarily, there will be little or no pain associated with the 
repair of the fracture. After about four weeks all apparatus 
should be removed and the limb thoroughly inspected, to detect, 
if possible, any uncorrected deformity, and to determine whether 
union is yet firm. In from four to six weeks repair in a 



29!^ FKACTLKES flF THE FEMLK 

healthy child or young adult should have advanced to the stage 
of firm union. The apparatus should then be reapplied. At 
the end of the eighth week all apparatus should be finally 
removed. The thigh should be washed and tlioroughly oiled. 
The patient should be permitted to lie in any position in bed 
without retentive apparatus for one week. After the splints are 
first left off and while the patient is still in bed daily systematic 
massage to the whole limb should be practised, together with 
slight passive and active motion at the knee-joint. The patient 
should not be allowed to bear weight upon the unprotected thigh 
until after the ninth week. At the ninth week he should be 




allowed up and about with crutches, and a moderately high-solcd 
shoe (two inches) should be worn upon the foot of the uninjured 
thigh. He should bear no weight upon the injured leg. The 
seat of the fracture should be protected by coaptation splints and 
straps and a light spica plaster-of- Paris bandage from the toes 
to above the waist. At the end of twelve weeks all support may 
be discarded. Of course, fractures of the femur vary considerably 
in the time the patient is able to get about, but the foregoing 
routine is that of average uncomplicated cases. 

It is very probable that massage without any passive motion, 
as early as the second week, to the region of the knee and thigh, 
will prevent much of the knee-joint disability and muscular 
atrophy that so often hinder convalescence in these cases. It is 



THE AMBULATORY TREATMENT 



299 



very important also, in order to gain this end, to see that the ex- 
tension is made from around and above the condyles of the femur 
and not, as so often happens, from the knee-joint itself. It ought 
to be possible to avoid all knee-joint stiffness by the judicious 
use of massage to the whole limb and passive motion to the 
knee-joint. These measures in many cases should be instituted 
and practised regularly and persistently and always cautiously 
from the second week after the injury. 

The ambulatory treatment of fracture of the thigh by means 
of the long Taylor hip traction splint, a high sole upon the 
shoe worn on the well foot, and crutches, is of very great value, 
especially in children and young adults. The hip-splint, con- 



Shaft of femur. 



Condyles and lower frajc 
ment of femur. 




Patella. 



Tibia. 



Fig. 415. — Low fracture of the shaft of the femur. Displacement of the lower fragment 
backward by the gastrocnemius muscle, and of the upper fragment forward. Overlapping 
of fragments. 

sisting of a long outside upright, pelvic, thigh, and calf bands, is 
applied with two perineal straps (see Figs 423, 424). The trac- 
tion is made through the windlass at the foot-piece after fastening 
the extension strips to it. The countertraction is made by the two 
perineal straps. The thigh is securely held by coaptation splints 
and a bandage about the thigh and splint. The patient goes 
about with crutches and a high sole of two inches upon the shoe 
worn on the well foot, bearing a little weight upon the foot of the 
.splint. As a matter of fact, the real value of this method in 
fracture of the thigh lies in the improvement to the general health 
by the early getting into the upright position and out of bed. 
This application of the ambulatory method certainly is of great 
comfort to the patient. That it hastens the reparative process is 



3CX3 KRALTURES Ol' THE FEMUR 

yet to be fully demonstrated. If the Taylor hip-splint is used, it 
should be applied when union is found to be firm. After wear- 
ing the splint in bed for a few days the patient may get up and 
be about. 

The Prc^DOSis. — What shall be considered a satisfactory re- 
sult in the treatment of a closed fracture of the shaft of the femur ? 
The degree of restoration of function can not be determined with 
accuracy until about one year has elapsed after treatment is sus- 
pended. The following six requisites for a satisfactory result fol- 




KiK. 41'i.— 
iKickwurcl iliiip 
diiplncemeiil i 

lowing fracture of the femur arc those reported by a committee 
from the American Surgical Association, and generally accepted 

as forming a good working basis. 

For a result to rank as a good one, it must be established 
that firm bony union e.\ists ; that the long axis of the lower 
fnigineiit is either directly continuous with that of the upper 
fragment or is on nearly parallel lines, thus preveiiling angular 
deformity ; that the anterior surface of the lower fragment main- 
tains nearly iis normal rt'Iatioii to the plane of the upper frag- 
ment, thu>; preventing undue deviation of the foot from its 



PROGNOSIS 301 

normal position ; that the length of the hmb is exactly equal to 
its fellow or that the amount of shortening falls within the limits 
found to exist in ninety per cent, of healthy limbs — namely, from 
one-eighth to one inch ; that lameness, if present, is not due to 
more than one inch of shortening ; that the conditions attending 
the treatment prevent other results than those obtained. 

Results After Fracture of the Thigh. — The prognosis as 
to the usefulness of the thigh after fracture deduced from the 
statistics available is of little value, because the details of the 




cases are not presented nor is any discrimination made between 
the seats of fracture and the ages of the patients. Realizing 
these facts, I have very carefully examined and classified the 
final results several years after treatment had ceased in thirty- 
five cases of uncomplicated fracture of the shaft of the femur 
treated at the Massachusetts General Hospital. The treatment 
in all cases was practically the same: a Buck's extension with 
outside T-splint, or a long Desault apparatus, and, toward 
the end of treatment, a plaster spica of the thigh, groin, and 
trunk, with crutches. Even though this number of cases is 



302 



FRACTURES OF THE FEMUR 



relatively small, yet, after having most carefully analyzed them, 
it seems highly probable that even if this number should be 
increased, the ultimate results would not materially differ. These 
thirty-five cases having been arranged in three groups, according 
to age : (a) Those of childhood ; (d) those of adult life ; and (t-) 




Ih spliuing «|>i>tH>[ 
lar rijioT upper fniRinciil. Palicnt 




— SamF ■■ figure 41 S, view from 



,.,.„..n 




those of old afje. (•t) Fourteen cases occurred 0/ childhood, the 
ages averaging seven and a h.ilf years. Patients were heard from 
or reported for examination one and a half to seven years after the 
original injury. All cases were treated by bed extension, coap- 
tation splints, and the plaster spica to thigh and hip. All have per- 



PROGNOSIS 303 

feet functional results. Four cases mention slight pain occasion- 
ally. Three of these four cases have a little stiffness of the knee 
upon the injured side one and a half years after the accident, three 
and a half, and three years respectively, (d) Sixteen cases oc- 
curred in aduits whose ages ranged from eighteen to forty-eight 
years. These were seen or reported from one to six years after the 
original injury. Five of these have unqualifiedly perfect results, 
without pain or stiflTness. The remaining eleven cases have 
limited knee-joint movement, aching in the thigh, pain after 




exercising, pain in wet weather, weakness in the whole leg, and 
slight lameness in walking, (c) Five cases occurred during oid age. 
The patients averaged fifty-eight years. These were seen or 
reported from two to six years after the original injury. None 
has functionally perfect results. There is one case of nonunion 
of the thigh with shortening of the limb. Two cases must use a 
cane in walking. The knee is painful and motion is limited in 
all cases. Swelling of the leg is not uncommon, and pain in 
wet weather is very commonly complained of by these old 
people. 



304 



FRACTURES OF THE FEML'R 



Considering these reported cases individually and grouped 
according to tlie three age periods, it seems reasonable to con- 
clude tliat they form a basis for a fairly accurate judgment as to 
the probable outcome of these injuries to the shaft of the femur. 
As the age increases the liability to impairment of the function 
of the limb increases. This liability is very great after fifty 
years are passed. 




*"^» 


1 





jyliul. 



lulaloiy spUni « 
ioii inllBU iDiy I) 
held by Miipi i\ 



It is not very uncommon, even in closed fractures of the femur, 
to find gangrene of the leg developing because of laceration or 
pressure upon the great vessels of the limb. Early amputation of 
the thigh just above the fracture will be necessary in these cases. 
It should be done early in order to save life. In the aged the 
shock of the accident may prove fatal. In open fractures the 



TREATMENT IN CHILDHOOD 



305 



H 



violence, usually direct, has been so great that the soft parts 
about the knee and throughout the whole thigh have been 
greatly torn and lacerated on either side of the fractured bone. 
The shock in these cases is severe. Recovery is always doubtful. 

Fracture of the Thigh in Childhood. — This is usually caused 
by direct violence. The fracture is often incomplete. The 
symptoms are those of the same fracture in the adult. The effu- 
sion into the knee-joint is seen perhaps more uniformly than in 
the adult. This effusion disappears from the child's knee-joint 
more quickly than from the adult knee-joint. 

Treatment. — After reducing the fracture, — making the incom- 
plete fracture complete if perfect reduction can not be accom- 
plished in any other way, — the problem of 
maintaining the reduction arises. 

In children of ten years and older it is pos- 
sible to use the Buck's extension. A plaster- 
of- Paris spica splint from the calf of the leg 
to the axilla is also a possible method of im- 
mobilization. 

In children under ten years of age the Cabot 
posterior wire frame with coaptation splints and 
extension is the very best method of conven- 
iently and efficiently treating a fractured thigh 
or fractured hip. 

The Cabot Posterior Wire Splint (see Fig. 
425) : The spHnt consists of two portions — 
a body part and a leg part. The patient lies 
upon the body part with the thigh and leg 
resting upon the leg part, as upon a coapta- 
tion splint. Having a vise and simple iron 
wire the size of an ordinary lead-pencil, this splint can be 
made in a few moments ; the bending of the wire according 
to the diagram and fastening the free ends by a strip of small- 
sized wire being all that are required. It is necessary to make 
the following measurements before bending the wire to the gen- 
eral shape shown in the diagram — namely, D E, the distance 
from the axilla to the calf of the leg ; A D, the width of the 
trunk ; A B, from the axilla to a point midway between the crest 




E'K- 425. — Cabot 
wire splint for fracture 
of the nip and thigh. 



20 



306 PRACTURES OF THE FEMUR 

of the ilium and the top of the great trochanter ; F E, the width 
of the leg, usually from two to two aiid a half inches. A D and 
B C are bent to the curve of the back-. B C is so bent that it 
jiimiTi over the .sacrum and does not t"itch pistcrinily excepting 




at B and C, The long rods are so bent as to adapt them to the 
posterior curves of the buttock, thigh, popliteal space, and leg 
(see Fig. 436). The splint is covered, as in the posterior wire 
splint for the leg, by layers of sheet wadding and cotton ban- 
dages. A swathe is attached to the two sides A B and D M of 



THEATMENT IN CHILDHOOD 3O7 

the body part (see Figs. 425 and 437). Tlic child is carefully laid 
upon this splint, tlie body swathes adjusted, the extension strips 
applied, traction made by weight and pulley with the foot of the 
bed elevated, coaptation splints applied and held in position by 
straps that include the posterior wire splint. If it is necessary 
to move the child for the making of the bed, for the use of the 
bed-pan, or for bathing, the extension may be unfastened tem- 




porarily without any injury to the fracture, particularly if the co- 
aptation splints are then temporarily tightened to secure a firmer 
hold on the thigh. The child should be, of course, clean from 
both urine and feces, and the fracture immobiiiited. 

After four weeks of bed-treatment the child may be up, with 
crutches and a high shoe with the Cabot splint applied. Shoulder- 



loS 



RtU-i UF THE I 



straps should be attached to the splint when it is worn in the 
erect position. This is one of the simplest, cleanest, and most 
efficient methods of treating fracture of the thigh in young chil- 
dren. The child can be moved witli freedom and without pain. 
A light pi aster -of- Paris spica bandage may be used in convales- 
cence with crutches and a high shoe on the uninjured side. 

In very small children it is sometimes wise to use the Brad- 
ford (see Fig. 428) frame and vertical suspension (see Fig. 429) 




of one or both thighs. This is an efficient, comfortable, and 
clean method of treatment. The Bradford frame is an iron, frame- 
like stretcher, on which the child lies and to which the shoulders 
and hips are fastened to prevent the child's moving about. 
Counterextension is then secured by the immobilization of the 
pelvis and hip. The extension is applied to the thigh and k-gas 
usual. The limb is flexed on the body to a right angle, coapta- 
tion splints being applied to the thigh. After the novelty of the 



SEPARATION OF THE LOWER EPIPHYSIS 



309 



position passes away, the child is perfectly contented. As soon 
as union is firm, the permanent plaster spica dressing may be 
applied, and the patient may be up and 
about with high shoe upon the well foot 
and with crutches. The use of the long 
hip-splint will be of great service in these 
cases either with or without the exten- 
sion foot-piece (see Figs. 423, 424). After 
fracture of the shaft of the femur in chil- 
dren there should be no shortening and 
no special difficulty in convalescence. 
It is wise to guard the thigh a sufficient 
time after union is firm to insure absolute 
solidity and freedom from bowing in any 
direction (see Fig. 430). 

The Making of the Bradford Frame. — 
It is most easily made from ^- to '/(-inch 
gas piping. It should be one inch wider 
than the width of the hips, and six inches 
longer than the height of the child. It 
should be covered with canvas, so as to 
leave a space under the buttocks for the 
use of the bed-pan. 



I 



'm 



SEPARATION OF THE LOWER EPIPH- 
YSIS OF THE FEMUR 

Anatomy. — The lower epiphysis ot 
the femur is the largest of the epiphyses. 
It unites with the shaft of the bone at or 
about the twenty-first year. The epiph- 
ysis includes the whole of the articular 
surface of the lower end of the femur. 
The points of origin of the gastrocnemii 
muscles are situated upon the epiphysis ; 

a few fibers only arise from the diaphysis. The inner condylar 
line of the femur is continuous with the inner lip of the linea 
aspera, and terminates at the adductor tubercle, which can 



Fijj. 431. — Femoral cpiph- 
vses at fifteen years. Note re- 
lations of lower epiphyseal line 
to inferior articular surface. 



FRACTLiRES OF THE FKMUI 




be palpaled upon the inner side of the tliigli near the knee- 
joint. The upjjer and outer angle of the trochlear surface 
of the femur can be palpateil best with the knee flexed. A Hne 
drawn from this angle of the trochlear to the adductor tubercle 
marks the level of the lower epiphysis of the femur (see Fig 431). 
In no position of the knee-joint are the botics in more than partial 
contact. This is one of the supcrfidLil joints of the body. The 




strengtJi of the joint lies in the ligaments and fascia.- about it. 
Unlike the elbow- and hip-joints, it does not depend upon the 
contour of the bones for strength. An attempt to ovcrcxtend 
and to bend the knee laterally brings very great strain to bear 
upon the ligaments that are attached to the lower femoral 
epiphysis. If this strain is ol sufficient force, the epiphyseal 
cartilage gives way, and the epiphysis separates from the shaft 
of the femur. The common cause of the accident is tlic catch- 




SEPARATION OF THE LOWER EPIPHYSIS 



311 



ing of the leg or thigh in the spokes of a revolving wheel. The 
accident most often occurs to boys about ten years old (see Figs. 

432, 433). 

The epiphysis usually separates without splintering the diaph- 

ysis. The periosteum is stripped for a considerable distance. 
About half the cases are open, the end of the diaphysis pro- 
jecting through the skin of the popliteal space. The knee- 
joint is usually unopened. There may be almost no displace- 
ment of the fragments. A lateral sliding of the epiphysis has 
often been observed. One condyle has been found in the 



Diaphysis of femur 




.Lower femoral 
epiphysis. 



— Patella. 



f Condyle of femur. 



Upper epiphysis 
of tibia. 



/-/ -Diaphysis of tibia. 

•Fibula. 



FiR. 434.--Lateral view. Case of figure 432. Boy, a^ed eleven years. Separation of the 
lower femoral epiphysis. Displacement forward of epiphysis and backward of lower end of 
shaft (see Figs. 432, 433. X-ray tracing). 



popliteal space, but commonly the epiphysis lies in front of the 
shaft of the femur with its separated surface in contact with the 
shaft (see Figs. 434, 43 5. 436). The diaphysis is displaced back- 
ward and downward into the popliteal space, because of the pos- 
sible high attachment of the gastrocnemii and the fracturing force. 
The nerves of this region may be pressed upon or lacerated, and 
this may be the cause of great pain attending the accident. The 
popliteal vessels may be compressed, stretched, or even ruptured. 
Consequently, interference with the circulation may result. This 
may be moderate and temporary, or extreme and result in gan- 



312 



FRACTURES OF THE FEMUR 



grene of the leg. The shock attending this accident is often great. 
Suppuration may appear in closed separations, although it is infre- 
quent ; it is much more likely to appear in open lesions. Slough- 



Epiphyseal line. 

Lower femoral epiphysis. 



Epiphyseal line of tibia. 

Epiphyseal line of fibula. 




Fig, 435. — Same case as figure 434. Anteroposterior view of uninjured knee in a child eleven 
years of age, showing epiphysis in position (X-ray tracing). 




/- — /-- Lower femoral epiphysis. 



Epiphyseal line of tibia. 
Epiphyseal line of fibula. 



Fig. 4 ;'».— Same case as figure 4.>4. Atitet opuslerior view of displaced lowci femoral epiphysis 

III a b<»v eleven vears old. 



ing of the skin is not unusual from bony pressure. Gangrene ot 
the leg sometimes occurs. Necrosis of bone is not unlikely to 
result, i^articularh' if the se|)aration of the periosteum is great 
(see Fig. 437). 



SKPARATION OF LOWER EPlPHVSfS 



3'3 



Diagnosis. — Afttr .severe trauma to the region of the knee 
there are three injuries that should be considered possible: a 
dislocation of the knee-joint, a supracondyloid fracture of the 
femur, or a separation of the lower epiphysis of the femur. 

There may be so much swelling that a satisfactory examina- 
tion is impossible. Ordinarily, careful palpation will detect the 
bony outlines of a dislocation. This is extremely rare in children. 
The crepitus of a supracondyloid fracture is bony and hard, and 
the displacement of the distal fragment into the popliteal space 



Upptr M.i|jhysi> of 







evident. All fractures at the knee are not necessarily supracondy- 
loid. Several cases of fracture of one condyle of the femur into the 
joint are reported. The separated epiphysis itself may be split 
through into the joint. A severe trauma to the knee, a cart- 
wheel accident to a young boy, attended by considerable shock, 
f.illowed by great swelling of the knee, a fullness in the pop- 
liteal space, feeble or absent pulsation in the dorsalis pedis and 
posterior tibial arteries, increased lateral and anteroposterior 
mobility at the knee, and soft crepitus form the picture charac- 
teristic of a separation of the lower femoral epiphysis. 



314 FRACTURES OF THE FEMUR 

Prognosis. — It is impossible to state positively that in anygiven 
case there will or will not be shortening of the leg upon the injured 
side because of a cessation of growth in the femoral epiphysis. If 
the epiphysis is separated without great laceration and periosteal 
denudation and is replaced soon after the injury, the chances are 
that there will be a minimum amount of shortening of the affected 
leg. After open incision and replacing of the epiphysis in closed 
fractures good results are to be expected as far as the useful- 
ness of the joint is concerned. Slight necrosis of bone may 




<Jiaph)sii 



attend convalescence. If the separation is closed and reduction 
is impns.siblo by manipulation alone, open incision .should be 
made. 

Treatment. — If the vessels are torn ; if there is great laceration 
of the .soft parts, amputation should be performed. If the sepa- 
ration is open and the shaft of the femur protrudes through the 
wnvind. and much of the diaphj'sis is seen to be denuded of 
[icriostcum, the diaphy.sis should be resected to the limit of peri- 
osteal >eparatinn, and then the bono reduced. It may be neces- 



SEPARATION OF THE LOWER EPIPHYSIS 



3IS 



sary to enlarge the opening in the soft parts before it is possible 
to reduce the bone. If the separation is closed, reduction by 
manipulation should be attempted : if successful, the leg should 
be flexed to a right angle or an acute angle and immobilized in 
a plaster-of-Paris splint. 

Reduction by Manipulation When the Fragment is Dis- 
placed Forward. — While an assistant makes traction upon the 
leg, the surgeon, grasping the thigh above the condyles with the 




Fi((- 439-— Diagram to show method of reduction of separated femoral epiphysis by incision. 
Retractors are upon diaphysis and epiphysis, and lines of traction are shown by arrows. 




Fig:. 440. — Cabot splint arrang:ed as double inclined plane for epiphyseal separation at the 
lower end of femur. B^ The part behind the knee-joint, may be bent to a more acute angle ; 
C the body portion, is to be molded to the trunk ; A, the foot-piece. With the angle at B 
obliterated, the splint may be used for fracture of the leg in childhood. 



fingers in the popliteal space, making pressure on the upper 
fragment, pushes with his two thumbs upon the upper border 
of the displaced epiphysis (see Fig. 438). The leg is gradually 
flexed. If the reduction is achieved, a soft grating sensation will 
have been felt, and the shortening of the leg that existed pre- 
vious to reduction will disappear. The contour of the knee will 
assume a somewhat normal appearance. 

The Operative Method of Reduction. — The obstacle to re- 



3l6 l-RACTLrRES OF THE FEMLK 

ductioii is no single band or obstruction, it is the retraction and 
tension maintained by tlic fasd;e, ligaments, and muscles of tlie 
thigh upon tlic tibia. This retraction is so great that the tibia is 
held crowded against the lower end of the upjicr fragment, and 
prevents the replacing of the epiphysis. An incision is best 
made over the denuded shaft of the femur on the outer side of 
the leg. The shaft and the epiphysis arc exposed in the wound. 
Traction should be made by means of periosteal retractors upon 
the epiphysis, and coimtertraction upon the diaphysis while the 
leg is slowly flexed from the completely extended position, as 




indicated in tiie figure (sec Mg. 437). This will result in the 
rcductii'u of the displacement. Suture of the bones may be 
ncedeil to retain tile replaced epiphysis in position. The flexed 
position of the leg will assist matcri;illy in retaining the fragment 
in piwition. Tiie applic.ition of a light-weight plaster-of-Piiris 
I ircular bandage from the tncs to ihc gmin. willi the leg flexed 
1. 1 a right ,.ngl,', v;ill immobili/e the i^rls. 

.\n. i-uiiinn is firm Ix-lween the cpijihysis and shaft. After 
iliiv,-,,.- r,,urwc,k< th,' legmayl.e gradually eMended. The 
r..,,l ■■( ih,- injure. 1 kg maybe t.mchcd K. ihc floor while the 
pl.i-trr siilinl i- in oi.icc about t'lve weeks aflcrthc injure'. Slight 



SKPAKAilUN OK THE LOWEK EPII'IIVSIS ^17 

wciglit may be borne upon it. The plaster should be rcniovcil 
after about six weeks, and gentle active and passive motion mado 
at the knee-joint. Massage to the calf of the leg and the thigh 
should be given daily. A flannel bandage applied to the foot, 
ankle, leg, and thigh will be all the support that is needed. 
After about ten weeks the boy should be allowed to step on the 







foot all he chooses. At first he will do this with fear, but soon 
wilh confidence. There will usually be a little limitation ol 
motion in the knee-joint (sec Figs. 441. 442). 

Traumatic Gangrene, Septicemia, Malignant Edema. — Frac- 
tures complicated with laceration of ihe large vessels are a fre- 
quent cause of gangrene. If an acute inficlious process starts 



3l8 FRACTURES OF THE FEMUR 

in a limb with traumatic gangrene, the gangrene spreads with 
frightful rapidity. The general disturbance is very great. A 
septicemia of grave type results. To such cases in which there 
is much gas formation, associated with edema, and which result 
in rapid destruction of tissue, the name malignant edema is given. 
The specific bacillus of malignant edema will be discovered in the 
blood and tissues far above the wound of the soft parts. 

The proper treatment is early high amputation with stimu- 
lation of the heart by strychnin and alcohol. 

Fat Embolism. — Fat embolism, to a greater or less degree, ex- 
ists in every case of fracture. It is most evidently present in those 
cases associated with great laceration of tissue and in open frac- 
tures. The soft fat of the medullary tissue is the source of the 
fat-drops that, getting into the venous circulation, are carried 
directly to the pulmonary capillaries, where they lodge unless 
the blood pressure is sufficient to force them out of the lung 
capillaries on into the systemic circulation. They then lodge in 
the brain, kidneys, or other organs. The danger in fat embol- 
ism is that the patient may die from asphyxiation, due to the 
imperfect oxygenation of the blood because of the rapid occlu- 
sion of the pulmonary capillaries with fat globules. 

Symptoms. — Symptoms develop within twenty -four to seventy- 
two hours after the accident. In fatal cases facial pallor and dis- 
tress are followed by cyanosis. The patient is first excitable, 
restless, then somnolent and comatose. Death occurs from 
asphyxia. 

The temperature is usually not elevated. Respiration is rapid. 
Hemoptysis may exist, associated with pulmonary edema. Fat 
globules will be found in the urine, for they are eliminated by 
the kidney. 

A difficulty in breathing, cyanosis, and fat found in the urine 
may be the only evidences of a fat embolism. The prognosis is, 
of course, dependent upon the extent of the embolism and the 
strength of the heart. 

TrcatDicnt. — Stimulation of the heart for its extra work is 
indicated. Immobilization of the fractured part to prevent more 
fat from pelting into the circulation and the administration of 
oxygen to relieve asphyxia are important in the treatment. 



CHAPTER XIII 

FRACTURES OF THE PATELLA 

Anatomy. — A knowledge of the anatomical relations of the 
patetl.iis necessary to a perfect understanding of the fractures to 
which it is liable (see Fig. 443). Attached to the patella upon its 




upper border is the tendon of the quadriceps extensor muscle. 
Upon each side of the bone are attached the vastus internus and 
vastus externus respectively. Below the insertions of the vasti 
is a portion of the low attachment of the fascia lata of the thigh, 
3'9 



FRACTURES OF THE I'ATELLA 



At tlio lower border <if the patella is the patellar tendon. This 
tendon is inserted into the tubercle of the tibia, and it is sepa- 




rated from the head of the tibia by a bursa and a pad of fat 
tissue. The tL-ndon of the quadriceps, the insertions of tlie vasti 
muscles, and the patellar tendon arc all continuous with the 



322 



FRACTURES OF THE PATELLA 



strong fascia lata surrounding the thigh. The fascia lata is 
attached below to the condyles of the femur, the sides of the 
patella, the tuberosities of the tibia, the head of the iibula, and 
to the deep fascia of the leg in the popliteal space. The patella 
is seen, therefore, to lie in a strong fibrous sheath that encircles 
the knee and is attached to various bony prominences (see Figs. 







444. 445, 446). The synnvial membrane of tJic knee-joint lies 
diroctl}' beneath and attached to the posterior surface of the 
[latulla. Laterally and posteriorly tJie synovial membrane lies 
next til tile encircliiii^ fascia of tiic joint. Tlie deep bursa of the 
femur lies in front of tJie lower end of the femur beneath the 
i|uadrice])-. niii^ek-s, and often communicates witJi the knee-joint. 



SYMPTOMS 323 

The tubercle of the tibia is on a level with the head of the fibula. 
The outline and anterior surface of the patella can be palpated 
throughout. When the leg is completely extended and is at 
rest, the patella can be moved from side to side. The numerous 
longitudinal strix on the anterior surface of the patella can be 
detected. In these the tendinous bundles of insertion of the 
rectus are embedded. It is these fibers that fold in over the 
broken patella and prevent the approximation of the fragments. 
The ligament of the patella is parallel with the axis of the leg. 

Fracture of the patella occurs through either muscular con- 
traction (see Fig. 448) and strain or through direct violence. 
The form of the fracture is not altogether dependent upon the 







causative force. The fracture will be either transverse and clean 
cut or comminuted and irregular. The knee-joint is generally 
opened : /. c, the synovial membrane is generally torn. The 
synovial membrane is reflected from the posterior surface of 
the patella some distance from the most inferior tip of the bone. 
It is possible, therefore, for a fracture to occur at the lower por- 
tion of the bone for some considerable distance from the lower 
edge without opening the knee-joint (see Fig. 449). 

Symptoms. — There are pain in the knee and immediate dis- 
ability, varying from partial to complete loss of power in ex- 
tension and in flexion. The patient may be unable to rise or, it 
he can stand, he can not move except backward, and then only 



324 FKACrURES OF THE PATELLA 

by dragging the foot ofthe injured limb upon the ground. The 
patient is often unable to raise the heel from the bed when lying 
upon the back. Swelling of the knee, which at first is slight, 
after three or four hours may become very great (see Fig. 
450V The swelling is due to the accumulation of blood and 
synovial fluid in the knee-joint. A traumatic synovitis exists. 
Immediately after the accident crepitus may be elicited by 
pressing the two fragments together. When the knee-joint 
is distended by fluid, it is often impossible even to detect the 
fragments of the jjatella, but as the fluid subsides and the sulcus 
between the bones is felt, crepitus can again be detected. The 
degree of the separation of the fragments is dependent upon tiie 



I 







amount of distention ol the joint and upon the extent of the 
tearing of the lateral aponeurosis (fascia lata) of the knee, per- 
mitting muscular contraction and retraction. If the causative 
violence is associated with a wound of the soft parts, there will 
be evident a contusion or an abrasion of the skin or a lacerated 
wound opening the knee-joint, making the fracture an open one. 

Treatment. — The indications to be met are the limitation and 
removal of the effusion, the reduction of the fragments, the main- 
tenance of the reduction until union is satisfactory, and the res- 
toration of the functions of the joint to its normal condition. 

The Limitation and Removal of the Effusion. — If the frac- 
ture is seen before there is great swelling, limitation of the 



EXPECTANT TKEATMENT 



swelling may be effected by immobilizalioii of the knee and the 
accurate application of an elastic rubber bandage. If the ban- 





Fig. .si.-FfKiut* of p«i.iia. Fibrous 

union with moderate sepanlioD; marked 
lilijng foiward of fiafinicnM ; no cnlarcc- 
nieiil of frainienli. View from tide. a. 
FIbrou) union ; ». extent of articular lur- 
face which is no* concave (W»nen Muse- 




inches (VVarien MuKum, 



■I of tragmenls 3K 



dage is not at hand, sponge compresses may be used — viz., two 
shghtly moistened bath or carriage sponges are allowed to dry 
under pressure sufficient to flatten them. These are placed upon 



326 FRACTURES OF THE PATELLA 

each side of the knee and over it, and are held by a few turns of 
a roller bandage. Cool water is then poured over the whole. 
As the sponges absorb tlie water they enlarge, causing equable 
and firm pressure on the knee, thus very materially hindering the 
accumulation of fluid and favoring its absorption. These wet 
sponge compresses should be left in position for from twelve to 
twenty-four hours, and then a fresh set used. 






Massage skilfully applied to the whole limb, irrespective of the 
method of treatment eventually instituted, will not only assist in 
the ah.sorpliiin of the fluid, but will preserve intact the muscles 
of the limb. Massage to be effective should be applied at least 
twice daily, and from fifteen minutes to half an hour at a time. 
.Sli;.;ht pain will be fell, but after a time massajjc will bo painless 
ami give great comfort. 



E.\ 1'1'XTANT TRHATMKST 327 

The Reduction of the Fragments. — No atlempt should be 
made to reduce the fragments until nearly all the fluid is removed 
from the knee-joint. Reduction is accomplished by immobiliza- 
tion of the knee-joint, by fixation of the lower fragment, and by 
traction upon and fixation of the upper fragment. The leg 
should be extended completely and the knee immobilized cither 




upon a ham-splint (see Figs. 45G. 457, 458) or upon a Cabot 
posterior wire splint. The ham-.'<plint is preferably made from 
a plaster-of- Paris bandage. The lower fragment is held fixed 
by a strap, preferably of adhesive plaster, placed obliquely about 
the leg and splint, and fastened to the splint above the fragment 
(see Figs, 459, 460. 461, 463). The upper fragment is drawn 
down first by elevation of the leg upon an inclined plane, 
which relaxes the quadriceps extensor muscle, then by trac- 



328 FRACTURES OK THE PATELLA 

tion obtained by a strap passed obliquely above the upper frag- 
ment aiid fastened to the splint below the fragmenl. The 
upper strap will need repealed adjustment as the plaster sh'ps 
and HR the fiiiid disappears from the joint. To facilitate trac- 






I 
I 



lion by ihis upper strap, the quadriceps muscle should be 
held firmly by coaptation splints and straps encircling the pos- 
terior splint. The quadriceps can not then actively pull upon 
the upper fragment. The tendency of these two straps thus 



apjilii^il will be to tilt the broken surfaces of ilie Iwu fragmtnls ^H 
upward and apart, particularly if there is fluid in the joint. It is ^^M 
important, therefore, to place a thini strap over the two broken ^H 
edges of the fragments, in order to hold them down to their ^^M 
proper level and to assist in bringing ihcm into apposition. Tlie ^H 
coaptation splints should be removed at every massage treat- ^^M 
ment. the upper fragment being steadied by an assistant. The ^^M 
straps about the patella need not be removed during the mas- ^H 
sage. They will be of no inconvenience. As soon as the ^M 




F(it. 4S1.— EippcUnl melhod of lT»lrnK iracmri o( Ihc pmclU. Samr al finulc i(rx. wll 
he aiJdJUoii oi Iwo lalcnil inlliiu. uiddiiiE. anil >trsn«. A iiDitetiai wooden still"!. •r'E 
>«llcr in Bguvt i6o. (nd elevKloii of (he limb. 

-ffusion has left the joint, all will have been gained in the rednc 
ion of the fracture that can be gained by this method. 

Aspiration of the knee-joint by means of a narrow knife inci 
ion or by means of a large-sized trocar is, if done under slrictl 
intiseptic precautions and forty-eight hours after the fracturt 
sften satisfactory in immediately removing the bulk of the effu 
ion; if firm compression is then made, it cflectually prevent 
he reaccumulalion of fluid. 

Maintenance of Reduction until Union is Satisfartory.— A 
he end of about four or six weeks from the injury union will b 
ound. All fluid will liave left the joint. The retentive strap 


J 



330 FKACTURES OF THE 

and coaptation splints may now be removed. The leg should 
be immobilized by means of a plaster-of-Paris splint extending 
from just below the swell of the calf to the groin. This splint 
is split on the side or posteriorly and arranged as a removable 




dressing. Proper batliing is facilitated. This enables the masseur 
to work. 

The removable splint is made thus : A light weight plaster-of- 
Paris roller bandage is applied to the properly protected leg from 
above the ankle to the groin, It is split in the median line 
its whole length before the plaster has quite hardened. It is 



H\PECTANT TREATMENT 33 I 

sprung off the leg. After it is hard a narrow strip of leather, 
upon which are fastened lacing hooks, is stitched to each cut 
edge. This splint may now be sprung on the limb and laced 
snugly in position. A leallier .>;plint may be similarly made 
from a plaster cast and mold of the limb. As soon as union 
is firm, the patient should be up and about with the light 
removable fi.sation splint applied, walking with the aid of 
crutches. 

Fixation (prevention of flexion and exten.sion) on walking is 
to be maintained for at least six months after the injury. Pro- 
tecting the knee thus when walking for this period of six months 







does not preclude active movements of the knee when not bear- 
ing weight upon the limb. At the end of that time ihc patient 
may be allowed to go about with a cane and a snugly fitting roller 
bandage (see Fig. 463). This bandage should be made of medium 
weight flannel, cut straight with the weave and not on the bias. 
The bandage should be applied from the middle of the calf of 
the leg to the middle of the tliigh when the leg is completely 
extended. As the patient becomes confident of his strength, the 
cane need not be carried. Sudden movements are lobeavoided. 
At the end of eight or ten months, varying with the individual 
case, all support may be omitted from the knee. 



333 



FRACTURES OF THE PATELLA 



The Restoration of the Function of the Joint. — rrom the 
day of the injury daily massage to the whole limb is important. 
It maintains the muscles in good tone. It prevents adhesion ol 
the fragments to the tissues about the condyles of the femur, a 
not uncommon cause of ankylosis of the joint. It facilitates the 
absorption of the effusion of blood and synovial fluid. After the 
fourth week dally passive motion is to be instituted : at first 
very slight indeed, barely two or three degrees. If the relative 




position of the fragments is not altered perceptibly by this pas- 
.five motion and lasting pain is absent, it maybe persisted in with 
regularly increasing amounts. At the expiration of eight or 
ten weeks active motion at the knee-joint may cautiously be 
allowed. The appearance of persistent and increasing tender- 
ness, sensitiveness, or pain, and increasing separation of the frag- 
ments are the indications to diminish or cease passive and active 
motions. 



EXPKCTANT TREATMENT 



333 



Summary of the Treatment of Fracture of the Patella by the 
Expectant or Nonoperative Method. — During four weeks fixa- 
tion of the knee, elastic compression, douching, massage, the 
thigh flexed slightly on pelvis, the leg extended, retentive straps, 
coaptation splints, are the measures employed. At the fourth or 
sixth week, remove all apparatus, apply removable splint, allow 
walking with crutches, and use daily passive motion. At the 
eighth week, discard crutches, use cane, and permit limited daily 
active motion. At the sixth month, discard splint, apply flannel 




/ 



I 

Fig. 466.— Fracture of upper third of patella, showing separation of fragments. Tilting of the 
upper fragment through rotation upon its transverse axis (X*ray tracing). 



bandage, and discard cane. At the eighth to the tenth month, 
remove all support. 

Open Fracture of the Patella. — This is a very serious in- 
jury, because one of the largest synovial cavities of the body is 
exposed to infection. It is safest and wisest to lay open the knee- 
joint, to thoroughly irrigate it with a solution of corrosive sub- 
limate (i : 10,000), and then with a sterilized normal salt solution. 
All blood-clots should be carefully wiped away. All loosely 
attached fragments of bone should be removed. Particular 
attention should be paid to the posterior parts of the joint, behind 



334 



FRACTURES OF THE PATELLA 



the condyles of the femur. It will be found convenient in clean- 
ing these parts first to flush the joint with sterile salt solution 
and to flex and to extend the knee. All parts of the joint pos- 
teriorly are thus likely to be thoroughly flushed. The fragments 
should be approximated and sutured by some absorbable suture. 
The skin-wound should be closed. The knee-joint should be 
immobilized in a posterior wire splint and side splints or in a 
plaster-of- Paris splint. 





Fig. 467. — Fracture of the patella in the 
lower third, showing tilting of lower frag- 
ment through rotation on its transverse 
axis (X-ray tracing). 



Fig. 468. — Fracture of lower edge ot 

ftatella. Little Sfparation of fragments, 
ndirect violence (X-ray tracing). 



Prognosis. — Ordinarily, an individual should not follow his 
occupation for about six weeks to two months after a fracture of 
the patella — /. c, unless the occupation can be conducted with 
a le<^ held stiffly at the knee. The functional usefulness of the 
limb and not anatomical considerations should be the chief crite- 
rion in determining the result following fracture of the patella. It 
a man can earn his living as before the accident without local dis- 
comfort or hindrance, he possesses a useful limb. It makes little 
difference if there is a slight separation of the fragments or a sug- 



PROGNOSIS AFTER EXPECTANT TREATMENT 



335 



gestion of a limp or slight atrophy of the thigh and calf muscles ; 
these conditions are all to be accepted as part of the irreparable 
damage, and are trivial. In nonoperative cases the union is 
usually fibrous, although it may be bony. The interval between 
the fragments may amount to five or six inches. The approxi- 
mation of the fragments of the patella is not evidence of strength, 
for the fibrous bond of union may be much narrower than the 
fractured surface and very thin, and thus easily ruptured. The 





Fig. 469. — Double fracture of patella without great 
separation of fragments (X-ray tracing). 



Fig. 470. — Transverse fracture ot 

{>atella, showing straps in position to 
lold fragments (X-ray tracing). 



usefulness of the limb after fracture of the patella is not 
dependent upon any one factor, either the kind of union or 
the extent of the separation of the fragments of bone. There 
are usually no adhesions of the upper fragment to the femur ; 
but injury to the bursa under the quadriceps may cause 
troublesome adhesions upon the anterior surface of the thigh. 
Full flexion is a common result, but there is often limita- 
tion of active extension. There almost always remains a little 
joint stiflhess, despite both massage and active and passive mo- 



33^ FRACTURES OF THE PATELLA 

tion ; this, unless due to fibrous adhesions, disappears gradually. 
The majority of cases of fracture of the patella under careful 
nonopcrativc treatment will secure a useful limb. A patella 
once fractured and having united by fibrous or bony union may 
be broken through the callus of the healed fracture or in an 
entirely different fracture from the first break. 

Results after Fracture of the Patella. — In a series of forty- 
seven cases of fracture of the patella treated at the Massachusetts 
General Hospital, occurring betvveen the ages of eleven and 
sixty-five years, four were over fifty years, thirteen were under 
twenty-five years, twenty-nine were between twenty-five and 




I 
\ 
\ 

\ 

\ 
\ 

\ 
\ 
\ 

I 
I 

I 
I 

I 
I 
I 

Fig. 471.— Comminuted stellate fracture of patella through direct violence (X-ray tracing). 

forty-fivc years, one was forty-seven years old ; practically, a 
young adult scries. Of tills scries of forty-seven cases ten were 
treated by operation and the remainder by the expectant method. 
These cases arc not mentioned in this connection to compare 
methods of treatment, but to determine the condition of the knee 
a loiiL^ time after the injurs-. As a matter of fact, there appeared 
no <4rcat(:r ficcdom from the s\'mptoms complained of among the 
cases operated on than among tliose unoperated. The results, as 
carefully recorded in tlicse fortv'-scven cases, suggest some of the 
difficulties that patients experience after fracture of the patella. 



OPERATIVE TREATMENT 



337 



The detailed reports of these cases, from one and one-half to ten 
and one-half years after treatment ceased, show that about twenty 
have as good a leg as before the accident. The remaining twenty- 
seven cases complain of limitation of motion at the knee-joint, 
that the knee creaks in walking, that it feels stiff, aches, and burns 
at times. The leg is said to be weak, and is troublesome in going 
up and down stairs — stepping up is especially difficult ; kneeling 
is painful ; stepping upon irregular surfaces is painful ; running 






Fig. 47a.— Old fracture of patella. Much 
separation of fragments. Small nodules of 
bone seen in the band of union (X-ray tracing). 



Fig. 473.— Old fracture of patella. 
Wide separation of fragments. Dimp> 
ling of sicin. A useful but not a strong 
leg (Massachusetts General Hospital, 
847. X-ray tracing). 



with the same freedom as before the accident is impossible ; the 
knee often gives way in walking and causes a fall ; the patient 
can not jump as before the accident, and walks with a slight limp. 
Pain is present in or about the knee in damp weather and after 
unusual exertion. 

Operative Interference in Recent Closed Fractures of the 

Patella. — In deciding whether a given case should be treated 
by operation or not the following considerations should be care- 



22 



338 



FRACTURES OF THE PATELLA 



fully weighed : A closed fracture of the patella does not in itself 
endanger life. It may be treated by the conservative method 
without added risk. If properly treated, the result will ordinarily 



Quadriceps tendon. 



Upper fragment of patella. 
Periosteum. 

Interposing tissues. 

Lower fragment of patella. 




Joint surface. 
Cartilage. 



Patellar tendon 



F>S- 474- — Median section of patella and tendons (diagrammatic), showing interposition ot 

fascia and periosteal shreds between the fragments. 







l'i>;. 4-5. -Frariiirc o! p.itcUa ; fru^jmciit appioxinialcd ami suttiiotl with silver wire. Wire 

sccti in Miu (X-ray tracing. C B. rorler 1. 



be salisf.icton' as far as the functional usefulness of the knee is 
concerned. The operative inethotl consumes less time in conval- 
escence and an excellent result is achieved, but operation exposes 



lTive tkeatm est 



339 



to the danger of sepsis. If sepsis results, the following conditions 
are imminent : A stiff knee, amputation of the ihigh. and possibly 
death from septic infection. Whether operation shall be done or 
not, therefore, depends upon the degree of safetj' with which it can 
be performed. It is the surest method of securing perfect apposi- 
tion and bony union. It should be undertaken only by surgeons 
of exceptional judgment and great skill, who have at command 
skilled assistants, and who can work under the most rigid aseptic 
conditions. The acute symptoms should be allowed to subside 




before operation. The tissues require time to recover them- 
selves from the acute trauma. The operative treatment should 
he confined to healthy individuals under sixty years of age ; to 
fractures with a separation of an inch or more of the bony frag- 
ments and extensive lateral fascial tears (the fascial tears may be 
recognized by joint distention and localized bulging) ; to cases 
presenting great joint distention that does not disappear quickly. 
It should be seriously considered if the individual's occupation 
is arduous and necessitates much standing or walking. The 
p.iticnt should be informed as to the probable outcome by the 



340 FRACTURES OF THE PATELLA 

two methods of treatment. The danger to life and limb should 
be fairly stated. It should be remembered that the power of 
extension of the leg is not materially limited by a transverse 
fracture of the patella in which the tearing of the lateral fascia 
is absent. Only in direct proportion to the extent of the lateral 
fascial tear is there limitation of the power of extending the leg 
upon the thigh. In open fractures, in refracture, and in cases 
of impaired function from long fibrous union or from adhesions 
of the patella or from badly united patellae mechanically imped- 
ing the movements of the joint, operation is always indicated. 
The working-man who wants to get to work should, under the 
conditions previously stated, have his patella sutured, for he will 
go to work quicker and have a better knee-joint than by any 
method of treatment. 

Method of Operation. — The joint and the fractured bones are 
to be thoroughly exposed by a transverse or longitudinal in- 
cision. All clots should be thoroughly washed or sponged out. 
Any loose small fragments of bone should be removed. In 
almost all cases a rather dense fascia will be found overlapping 
the broken surfaces of the two fragments (especially is this seen 
in a transverse fracture). These bits of overlapping tissue or 
curtains of tissue should be retracted and removed or utilized in 
suturing the fragments (see Fig. 474). Whether silver wire is 
employed to suture the bone directly or whether an absorbable 
material is used to suture the soft parts seems of little conse- 
quence as long as all fascial tears are sutured and the bony frag- 
ments are approximated (see Fig. 475). The weight of opinion 
to-day is in favor of absorbable sutures. Closure of the joint 
without drainage and immobilization in the extended position 
followed by the treatment already mentioned are indicated (see 
Fig. 476). 

The Restoration of the Function of the Joint Following the 
Operative Treatment. — After suture of the patella, massage and 
Identic passive motion should be begun at the end of two weeks. 
At the end of three weeks the patient may go about with the 
knee protected b\' a light stiff dressing. After about six weeks 
to two months a flannel bandage and a cane will be all the pro- 
tection needed to the knee. At the end of three months the 
knee should be functionally perfect. 



CliAI'THR \1V 

FRACTURES OF THE LEG 

Anatomy. — The following alriictures may be palpated : The 
internal and external tuberosities of the tibia." the whole of the 
external tuberosity being subcutaneous ; the broad anterior 



l"^. 



and inner surface of the tibia, which forms the shin, downward 
to the internal malleolus ; the sharp crest of the tibia through- 
out its whole length ; the head of the fibula, an inch below 



342 



FRACTURES OF THE LEG 



the top of the tibia ; a little of the shaft of the fibula below 
the head and the attachment of the biceps tendon ; the lower 
third of the fibula which is subcutaneous. The tubercle of the 
tibia is distinctly felt on the anterior surface of the upper end of 







the tibia. It is one inch from the articular surface, and marks 
the lowest limit of llic upper epiphysis of the tibia. Into it is 
inserted the p;itollar tendon. The .shaft of the tibia arches 
shfrhtly fi>nvard. The .shaft of the fibula arches .lifjhtly back- 
ward. Tile broad inner malleolus is liijjlier than the outer 



ANATOMV OF THE TIBIA AND FIBULA 



343 



malleolus, and more to the front of the leg. The outer malle- 
olus is narrow. The posterior edges of the two malleoli are in 
about the same plane. The anterior edge of the external malle- 




olus is about an inch behind the anterior edge of the internal 
malleolus. The narrowest part and the weakest place in the 
tibia is at the junction of the lower and middle thirds of the 
bone. In the normal leg the middle of the patella, the tendon 



ANATOMY OF THE TIBIA AND FIBULA 



345 



of the patella, and the midpoint of the ankle are in the same 
straight hne (see Fig. 477). 

General Observations. — Fractures of the tibia and fibula may 
occur at any point, depending upon the seat and direction of the 
fracturing force. If the force is indirect, the fracture of the two 
bones will be at different levels. If the fracture is high up, tlie 







Fig- iSs.— FracluTc of both bonei 
the Ick; dliplacrmciit of upper rrajimc 
dowinvird ind iiiwaiJ ( union (Wm 
MuKum, ipccincn 8303). 



knee-Joint may be involved or the popliteal vessels and peroneal 
nerve may be implicated. If the fracture is low down, the ankle- 
joint may be involved. The high fracture of the tibia is usually 
transverse. The low fracture of the tibia is usually oblique. The 
common seat of fracture is at about the junction of the middle 
and lower thirds of the leg. The line of the fracture is an 



r 


346 FRACTURES OF THE LEG 

oblique one, extending from above and behind downward and 
forward tlirougii the tibia. The fibula is fractured a little higher 
than the tibia. If the force is considerable and the sharpness ol 
the fragments great, the overlying skin may be lacerated, an 
open or infected fracture resulting. The upper and lower epiph- 
yses of the tibia may be separated ; these are, however, rare 
injuries. The tibia and fibula may be fractured separately. In 
such cases the unbroken bone serves as a splint for the fractured 
one. The disphcemcnt in these latter frnctures is slight. 


1 


L 


Examination of a Fractured Leg.— It is someiimes ex- 
tremely difficult to detect a fracture of the leg. It is, therefore, 
important that a systematic examination should be made imme- 
diately after the injury. Deformity will ordinarily be apparent 
upon inspection (.see Fig. 48S). Gentle manipulation will suffice 
to satisfy one of the existence of a fracture, particularly if both 
bones are broken. An open fracture will be evident if a wound 
exists in the skin near the seat of fracture. In taking hold ot 
the leg for examination or for moving the leg it should not be 
grasped lightly by a few fingers but by the whole hand firmly, 
as one grasps an ax handle in chopping wood ; not as one 


1 



METHOD OF EXAMINATION 



347 



lifts a lead-pencil from the table. The leg should be so raised 
in making the examination that there is absolutely no risk of con- 
verting the closed fracture into an open one. In order to guard 
against this the assistant should grasp the foot at the ankle and 
make gentle but strong traction in the long axis of the leg as the 
whole leg is raised. This care in examination will cause the patient 
a minimum amount of pain. Crepitus is not the only thing that 




Fig. 487.— Fracture of both bones of the left le^. Comparative height of knees to show 

shortening of leg (after Van Lennep). 



is to be sought at the examination. The freedom of any ab- 
normal mobility should be noticed, as well as the direction of the 
motion, the ease with which reduction is possible, and the liability 
to recurrence of the deformity. If there is any doubt as to the 
seat or extent of the fracture, the examination should be made with 
the assistance of an anesthetic. The temporary dressing may 
be applied at this time. The bones should be palpated. While 



34^ FRACTURKS OF THK LE« 

an assistant steadies the knee-joint the surgeon, grasping tlie 
lower part of the leg, attempts motion in each direction. Simply 
raising the leg and attempting motion in an anteroposierior direc- 
tion is not sufficient ; a fracture of the tibia, if transverse, might 
remain completely locked except upon lateral movement. The 
tibia should be measured (sec Fig. 4S6) from the knee-joint line, 
at the upper border of the internal tuberosity, to the lower edge 
of the internal malleolus to determine shortening. Shortening 
of the leg may be roughly estimated after union of the bones by 
comparing the height of the two knees while the soles of the feet 
rest upon the floor (see Fig. 4S7). The measurement should 
be compared with that of the uninjured tibia. It ts often difficult 
in fractures near the ankle to palpate the internal malleolus, on 



I 



narm!S'*^Mo'of 



b figure J79 ol 



account of swelling. Deep pressure with the thumb will detect 
it. Inquiry should be made as to whether either tibia has ever 
been fractured previously. The pulse should be felt for in the 
posterior tibial and dorsalis pedis arteries to be sure that the large 
vessels of the leg arc intact. 

Symptoms. — Ordinarily, the presence of pain, deformity, 
abnormal mobility, crepitus, and loss of use of the leg will be 
the evidences of fracture. If the fracture is of the tibia or libula 
alone and transverse without much displacement, localized ten- 
derness upon pressure and swelling will be the only signs. It is 
important to remember the backward bowing of the tibula in at- 
tempting to localize by palpation the tender point of the fracture 
of that bone. 



SYMPTOMS 



349 



The deformity is due to the displacement of the upper frag- 
ment forward and of the lower fragment upward and backward. 




I 

Fig. 489. — Fracture of the tibia,obliaue and high up. Almost no displacement (Massachusetts 

General Hospital, 1335. X-ray tracing). 



Femur.—. 



Tibia. 




Patella. 



Fibula. 



Fig. 490.— Fracture of the external tuberosity of the tibia (Massachusetts General Hospital, 

1242. X-ray tracing). 



If the fracture is oblique, this displacement will be considerable. 
The lower fragment is often rotated upon its longitudinal axis, 
so that the foot rests upon its side, while the upper fragment 



3SO FRACTURES OF THE LEG 

remains undisturbed by rotation, the patella looking directly 
upward (see Fig. 488). 

Tlie swelling will vary. It may be extremely slight and 
limited to the seat of the fracture or it may extend over the 
entire leg. The maximum swelling of the leg is usually reached 
three or four days after the accident. If the fracture was caused 
by direct violence and the fragments of bone are sharp, the soft 
parts will be damaged and the resulting hemorrhage and swell- 
ing will be very considerable. 





4qi--Loi.giludinml RxunnE ot 
mbUsUngBccidini. Lilerillvlfw. 



Kcchymosis of the skin appears in from twenty-four to forty- 
eight hours after the accident ; it may extend over the whole leg. 
I-xcliymcKSLs from a sprain is localized more or less about the seat 
<if the sprain ; that from a fracture is often extensive. Blebs or 
vcsiulu's may ajjjjcar near the fracture during the first week if the 
.swelling is great. It is necessary to exercise great caution in the 
care uf these bleb.s, that they do not become infected. 

Fracture of the -.haft of the fibula may be very obscure, but 
pressure upon the fibula toward the tibia will elicit pain and 



TREATMENT 



351 



crepitus. In separation of the lower epiphysis of the tibia the 
preservation of the normal relations between the malleoli is of 
considerable diagnostic importance. 

Treatment. — For purposes of treatment fractures of the leg 
are arranged into several distinct groups — viz.: 

1. Fractures with little or no swelling or displacement 

2. Fractures with considerable swelling. 





Fig. 493. — Oblique fracture of the tibia 
low down, and oblique fracture of the fibula 
at its middle (X-ray tracing). 



Fig. 404.— Fracture of both bones ot 
the leg at the middle ; slightly spiral of tibia 
(Massachusetts General Hospital, X134. 
X-ray tracing). . 



3. Fractures with a displacement of fragments difficult to hold 
corrected. 

4. Open fractures. 

The indications to be met by treatment in each of these groups 
are correction of deformity, immobilization of fragments, and res- 
toration of the limb to its normal condition. 

Fractures with Little or No Displacement or Swelling. — 
Fractures of the tibia alone or the fibula alone are properly 



352 



FRACTURES OF THE LEG 



placed in this group. Fractures of both bones occasionally 
occur with tittle or no displacement and with but a trifling 
amount of swelling. In these cases the leg should be elevated 
for ten minutes in order to lessen the swelling. The foot, leg, 
and lower thigh are then bathed with soap and water, and 
thoroughly dried and powdered. The leg being properly pro- 




f'iL- 49s.— Oblique frscluce of tioLh 
boiiM of ific IcK- Dijplacement of iht 




tected, a light plaster- of- I'aris roller bandage is applied from 
the tiies to the middle of the tliigh. (See Details of Plaster 
Work.) The leg i,s to be kept elevated for the first week by 
at least two or three pillows. If good judgment is exercised 
in the subsctpicnt care nf the case, the placing of such a frac- 
ture, as previously indicated, immediately in a pla^ter-of-Paris 
s])iint i-; atleiided by no risk. The danger lies in too great 



TKEATMENT 353 

pressure upon the circulation, caused by the increasing swelling, 
of the leg within the unyielding plaster splint. Pressure sores 
and gangrene are liable to result. In applying the splint a 
liberal amount of sheet wadding should be used. The condition 
of the circulation should be noted immediately after the application 
of the splint and at regular intervals thereafter until all danger 
from undue pressure has ceased. Evidences of too great pressure 
are persistent or increasing swelling of the toes, blueness of the 
toes, and pain It is well, in order to avoid undue pressure upon 
the leg, to split the plaster the entire length of the splint before 



Fig. 497 -Doi 
General Hospiol 




it has quite hardened. The splint loses by this procedure none 
of its immobilizing qualities, for it can be bandaged or strapped 
tightly together again. Too great pressure upon the circulation 
can then be immediately relieved by loosening the retaining straps 
or bandage and thus opening the splint. After the splint has been 
on the leg for about a week and a half or two weeks, the swell- 
ing having begun to subside, the plaster splint will become loose 
and will cease to hold the fragments firmly. Unless a new and 
.snug splint is now applied, it will be necessary to cut out a 
strip of plaster an inch or more wide from the old sphnt to admit 



354 FRACTURES OF THE LEG 

of tightening. During the changing of the plaster splint the leg 
should be steadied by an assistant while it is thoroughly washed 
with soap and water and bathed with alcohol. 

Fractures with Considerable Immediate Swelling:. — Many 
fractures are not seen by the surgeon until two or three hours 
after they have occurred, when considerable swelling is present. 
Associated with such primary swelling there will be laceration 
of the soft parts and possible extensive injury to the bone. 
HIebs filled with clear or bloody serum may be present about the 





f'c'sr- 



seat of fracture. These should be evacuated after the part has 
been rendered surgically clean by washing with soap and water 
and corrosive sublimate solution, and then dressed with a dry 
antiseptic powder, powdered dermatol, or aristol. Infection may 
take place through blebs. Very great care should be exercised 
in their treatment. Obviously, it is unwise immediately to apply 
a plastcr-of-1'aris splint to cases in which there are many blebs 
and much swelling. The swelling of the leg may become so great 
that the life of the limb may be at stake, the danger from im- 
pending gangrene becoming imminent. In such cases the skin 



TREATMENT 355 

of the leg becomes tense and shiny, the leg feels hard and board- 
like, pain may be extreme, and the toes and foot become slightly 
blue. The hemorrhage, being confined beneath the fascia and 
skin, causes pressure upon the circulation. The circulation in 
the leg is thus impeded. Under such circumstances operation is 
necessary in order to relieve tension and to check hemorrhage. 




jIigDod. Sin. 

SDi (MMUch Ulcus Gcnin 
. S-taytrscini) (Scudder; 



Incisions in the long axis of the limb through skin and fascia 
will be followed by a rapid decrease in the .swelling of the 
leg and a cessation of the pain. After incision, the bleeding 
vessels found should be ligated. The bones may be sutured at 
this time if it is thought wise. If these wounds remain aseptic, 
they may be clo.sed after a few days by suture or may be allowed 



r 

1 


356 FKACTUKES OP THE LEG 

to heal openly. This method of treatment will usually result in 
saving the leg (see Fig^s. 502, 503). If tlie circulation does not 
return and gangrene is imminent, immediate amputation of the 
imb wcW above the fracture at the lower or middle third of the 

Fig. 503.— Case; Closed fnctute ii( ilic h-fi [ibu. Htmntomii. Imi.aitiiicm iil ilitciicU' 
atior. F.« i.,i-lsionv Eva^u.nlU,,, of Nn™l. Relief of |.u-ss„rf. L« ^.ive.!. Heto.e., 


1 

1 


•J 


'^n^^ 




* ^* *Hli sltaps. O^n end of iL ^.llow-cw »t%z ImI. '' 

thigh is the only procedure. Traumatic gangrene is often rapidly 
bllowed by general septic infection. It is best to use a tem- 
jorary dressin[i in cases in which there is great initial swelling 
of the leg. 


J 



TKEATMENT 357 

The Temporary Dressing. — The Pillow and Side Splints. — 
The leg is placed on a pillow covered with a pillow-case ; straps 
are placed under the pillow and drawn snugly up about 
the leg (see Fig, 504). The edges of the pillow arc rolled in 
against the leg for firmness. Narrowly folded towels are placed 
between the leg and the straps. The straps are then drawn 
tighter. The open end of the pillow-case is folded and pinned 




under the sole of the foot. Three pieces of splint wood arc 
introduced between the pillow and straps — one is slipped under- 
neath and one upon each side of the pillow. The pillow 
thus serves as a padding for the box formed by the splint wood 
(see Fig. 505), Ice-bags may be conveniently placed along the 
anterior surface of the teg between the edges of the pillow. They 
relieve pain and arc said to check hemorrhage immediately after 



I 



I 



35° FRACTtTRES OF THE LEG 

the fracture. If greater security is thought necessary, the pillow- 
case, instead of having its sides rolled in, may be pinned with 
shield-pins up over the anterior surface of the leg (see Fig. 506). 




di<q.l». 



This temporary dressing is left in place for a week or a week and 
a half. The swelling will then have partly subsided. If at this 
time there i.^ little or no swelling and the displacement is slight. 



TREATMKNT 359 

a pi aster -of- Paris splint may be applied as a permanent dressing ; 
it is split or not as circumstances indicate. If, on the other 
hand, at the end of a week or a week and a half it is desired to 
have the fracture open to inspection and more directly accessible 
and under the eye of the suryeon, then the posterior wire and 
side splints should be applied. 

The Permanent Dressing *or Fracture of the Leg. — Several 
important things are to be kept constantly in mind in placing a 
fractured leg in a permanent splint. They are as follows : The 
alinement of the bones of the leg is to be maintained ; rotation 
of either fragment upon its long axis is to be avoided ; the foot 
is to be kept e.tlended to a right angle with the leg ; lateral devi- 
ation is to be avoided ; the inner side of the great loe, the middle 




of the patella, and the anterior superior spine of the ilium should 
be in one straight line ; anteroposterior deformity is to be avoided 
(the convexity of this curve of deformity is usually backward ; it 
is a hyperextcnsion of the leg at the seat of fracture) (see Figs. 
507—509) ; frequent measurements and inspection of the leg 
should be made ; inspection should be made not only from the 
front, but laterally as well ; readjustment of apparatus is neces- 
sitated by changes in the position of the bones. 

The Posterior Wire and Side Splints. — The posterior wire or 
Cabot splint is made of iron wire the size round of an ordinary 
lead-pencil {see Fig. 510). It is applied to the back of the foot, 
leg, and thigh, extending from just beyond the tips of the toes to 



360 FHACTURES OF THE LEG 

above the middle of the thigh. It is narrow at the heel and broad 
enough above to permit the thigh to rest comfortably upon it. 
The foot-piece is at right angles to the leg. 

Having at hand the iron wire the .size of an ordinary lead- 
pencil, this splint can be quickly and easily made by means of a 



io)^'fi)*wii1 




vise for holding the wire, and a wrench for grasping the wire 
while bending it. The two free ends of the wire of the splint 
may be held firmly together by having them overlap and bind- 
ing them together with small-sized copper-wire. These free 
ends may, of course, be held by solder. 

The Covering of the Posterior Wire Splint. — The wire is 



THE CAKE OF THE HEEL 361 

wound first with a roller of sheet wadding, then with a cotton 
roller, and finally a cotton roller bandage is wound about both 
sides of the splint so as to make a posterior surface upon which 
the leg may rest (see Figs. 510, 511, 512). 

The side splints of wood (see Fig. 513) should be about four 
inches wide, and long enough to extend from the foot-piece to 
the top of the splint. The side splints may be covered with 
sheet wadding and cotton cloth, as seen in the figure. 

Care of the Heel. — If but slight pressure is maintained upon 
the heel even for a few days, a pressure sore will develop. This 
is liable to increase to a considerable size. It is very slow in 
healing. Many weeks after the fracture of the leg has united 
the pressure sore may be open. It is. therefore, of very great 




importance to prevent pressure upon the heel during the treat- 
ment of fractures of the lower extremity associated with dorsal 
decubitus. There are four metliods of avoiding pressure on the 
heel. Position will assist materially. The position of the foot 
largely determines the amount of pressure falling on the heel. 
When the foot rests naturally, it is in the position of slight 
plantar flexion. The heel presses firmly upon the splint (see 
Fig. 514)- A large part of the weight of the leg thus falls upon 
the heel. When the foot is extended to a right angle with the 
leg. the pressure upon the heel is, in a large measure, removed 
(see Fig. 5 1 5). Therefore, in putting up fractures of the leg the 
right-angle position is the desirable one. Padding above the 
heel is of service. The ring or doughnut pad arouiKl the heel 



I 



36j FKALTUKK5 OF THE LEG 

is sometimes elificieiit. Slinging tlie foot by adhesive straps ap- 
plied to the sides of the heel and foot and fastened to the foot- 
piece of the sphnt is a very satisfactory method of removing 
pressure from the point of the heel (see Fig. 516). 

The Padding of the Posterior Wire Splint for the Reception 
of the Lower ICxtremity. — Regard should be had for the natural 




curves of the leg and thigh posteriorly (see Fig. 5 1 5), Above the 
heel, behind the knee, and below the buttock are distinct hollows, 
at which places the padding, as indicated in the illustration, 
should be thicker than at other points. Regard should likewise 
be had for the natural lateral curves of both thigh and leg. Just 
below the malleoli, above the ankle, below the knee, and above 




TH1£ PADDING Ol-" THK POSTERIOR SPLINT 363 

the knee are distinct hollows tliat will require more padding than 
elsewhere on the sides of the limb (see Fig. 517). The more 
carefully the splint is padded, the more nearly perfect will be 
the result of treatment and the greater will be the comfort of the 
patient. 

The ley is to be placed upon the posterior wire .splint, so 
padded posteriorly that it rests naturally and comfortably. The 
foot should be placed at a right angle, drawn down snugly to the 




foot-piece, and steadied by adhesive-pla.ster straps carried around 
the foot and splint in a figure-of-eight bandage (see Figs. 519. 
520). The side splints, so padded with pillow-cases or towels as 
to bring suitable pressure upon the leg and thigh, are applied and 
held in position by straps and buckles (see Fig. 520). This splint 
immobilizes the knee- and ankle-joints and the fractured bones. 
The re^^ion of the fracture is open to inspection anteriorly. 
Lateral inspection is facilitated by loosening iht straps and lower- 



364 



FRACTURES OF THE LEG 



ing the side splints. Any deviation from the normal lines of the 
leg can be adjusted easily. At the end of three weeks, when the 
fracture is uniting and the callus is still soft, the leg should be 
removed from the splint and examined carefully from the front, 
from the back, and laterally for any deviation from the normal. 
If any deviation is discovered, it should be corrected and the leg 
put again into a posterior wire splint or into a removable plaster- 
of- Paris splint. 






Fig. 51b. — Methods of supportinK the foot in fractures of the leg when using a posterior splint, 
a, Padding beneatli tendo Achillis; b, ring under heel : c, sling of adhesive plaster. 



The first night after putting up the fracture the patient will 
probably be most uncomfortable. The new and restrained posi- 
tion, the aftcr-cfifect of the anesthetic if one has been used, the 
points of undue pressure yet to be adjusted, the itching of the 
skin, the inability to move about, the necessity of lying in one 
position, actual pain at the seat of the fracture — all combine 
to make life miserable. It will be a wise precaution on the 
part of the attendant if a little morphin is administered subcu- 
tancously this first ni<^dit, as patient, nurse, and physician will 



TREATMENT 365 

rest better. After the first night there will, under ordinarj- cir- 
cumstances, be no especial difficulty. After the plaster splint is 
applied the Smith anterior wire splint attached to the anterior 
surface of the thigh, leg, and dorsum of the foot often will enable 
the leg to be slung just so as to clear the bed. This position is 
one of considerable comfort. The patient is enabled to move in 




bed a little and lo change his position without disturbing the 
fracture. This anterior wire splint is made, like the Cabot pos- 
terior wire splint, of iron wire, but is fitted to the anterior surface 
of the foot, leg. and thigh (see Fig. 518). 

Fractures Difficult to Hold Reduced. — These arc usually ob- 
lique fractures of the tibia, occurring most often in the lower 



366 FKACTtJRES OF THE LEG 

half of the bone. The nearer to the ankle-joint the fracture is, 
the greater is the hkelihood of a displacement which is hard to 



Alih,^ 


ool. ^" 


sntns 




^ 


^ 


^ 


p,*^=fc=rV 




I 



I 



hold reduced. The contraction of the quadriceps extensor tends 
to pull the upper fragment forward, the contraction of the gas- 
trocnemius tends to pull the lower fragnu-nt backward and 




TKtlATMEST 

iipwaiii. The obliquity of the fracture and the action of these 
two groups of powerful muscles make it almost an impossibility 
to hold these fractures reduced. It is often, even under an 
anesthetic, impossible to correct the deformity without doing a 




e^iop of ihc ., 

le rooi-piMt. TIglilcninc Iht 



tenotomy of the tendo Achillis. A posterior wire and side splints 
with the foot held fixed, with a moderate traction and pads placed 
at the seat of fracture, may be of service, 

A plaster-of-I'aris splint with extension and countcrcxtension. 
after the principle of the Short-Desault apparatus and according 



1 


368 FRACTURES OF THE LEG ^^M 

Lovett's adaptation (see Figs. 521. 522), will hold some of the ^H 
more difficult cases. ^1 
Afct/ttxi of Application of the Traction Plaster-of-Paris Splint.— ^H 
!^rom the seat of fracture running upward and from the seat ^^| 
of fracture running downward are applied extension adhesive ^^| 
plasters, with webbing attachments, as seen in the diagram (see ^H 
Fig. 522). Below the foot, the size of the sole of the foot and ^H 
two inches thick, is held a very firm pad of sheet wadding. A ^H 
>laster bandage is apphed to the leg, according to the usual ^^| 
methods, from the toes to above the knee. A buckle looking ^H 
upward is incorporated in the plaster bandage upon each side ^^| 
of the leg a little above the level of ihe knee. A slit is left ^| 


1 


^^Hl 






tar lea 'ro"> 'he spUiil. 

Upon each side of the ankle for the lower extension webbings tc 
come through (see Fig. 522). After the plaster has hardeneL 
the sheet-wadding foot-pad is removed. The upper exiensior 
straps are pulled snugly over the upper edge of the plaste 
sphnt and fastened to the buckles on each side. Then the lowc 
straps are pulled taut over the foot-piece of the plaster. Coun 
tertraction and traction are thus maintained upon the fragment 
of the fracture. A window is cut in the plaster to observe iht 
aosition of the bones. This apparatus is efficient in many in 
stances in which it is otherwise difficult to maintain reduction. 

Operative interference with suture of the fragments of bone i 
the most effective method of treatment in troublesome cases. I 
IS always wise to delay operating until after the primary effect 


1 



TREATMENT OF OPEN KKACIL'RES 369 

of the injury have ceased — that is, until after the acute swelling 
has subsided and the damaged tissues have had time to recover 
themselves. A delay often days is time gained. During these 
ten days some one of the methods already mentioned may suc- 
ceed in holding the fracture satisfactorily so that operation is 
unnecessary. 




Treatment of Open Fractures of the Leg. — Treatment rests 
upun tlic presumption that every open fracture is infected. The 
object of treatment is to convert the open infected fracture into . 
a closed noninfccled fracture. It is important that the first dress- 
ing of the wound should be a clean one. If it is a temporary 



A 



370 



FRACTURES OF THE LEG 



dressing, the wound should be douched with boiled water, cov- 
ered with a clean absorbent dressing, and the leg be placed upon 
a pillow splint. 

The Permanent Dressing. — Every open fracture of the leg 
should be anesthetized for careful examination, diagnosis, and 
the initial dressing. The leg should be washed with soap and 
water and scrubbed with a gauze sponge or soft nail-brush. The 
leg should be shaved of all hair in the vicinity of the wound, 
and should then be washed with liquor sodae chlorinatae (chlor- 




Fijf. 525.— Fracture of both bones of the leg. Ununited fracture of tibia. Fibula united 
(Massachusetts General Hospital, 1190. X-ray tracing). 



inated soda), one part to twenty. This will most effectively free 
it from all grease and oily dirt. 

The Wound of the Soft Parts. — This should be moderately 
cnlar^^ed to allow easy access to its deeper parts. There are, 
no doubt, cases of fracture of the bones of the leg open from 
within outward in which the wound is small, evidently made by 
the bone, in which it is prudent to seal the wound and to regard 
the likelihood of infection as absent. These cases, chosen in 
the jud<^ment of a wise surgeon, may do well, but they may not ; 
therefore, the author believes it is safer to advise that all wounds 



ENT OF OPEN FRACTURES J7I 

of open fractures be enlarged for thorough cleansing. The blood- 
clot and detritus should be washed out by irrigating with a warm 
solution of corrosive sublimate, i ; 5000. Irrigation should be 
supplemented by thorough scrubbing of the tissues of the wound 
by small gauze swabs held in forceps. These swabs should be 
small enough to be carried into all the recesses of the wound. 




All bleeding should be checked. Loose bits of muscle, fat, 
fascia, and bone should be removed. Often the finger will 
detect bits of bone when the forceps will not. The firmly 
attached fragments of bone are to be left undisturbed. Regard- 
ing the treatment of the slightly fixed fragments of bone, the 
surgeon mu-st judge in each instance. It is a good rule when in 



372 



FRACTURES OF THE LEG 



doubt about the viability of a fragment of bone to i 
The deep fascia may need division to permit of ;i view of the 
depths of the wound. The fractured bones are then lo be approx- 
imated and sutured, if practicable. The comers of the wound 
may be sutured. It is wise to leave the wound open enough to 
receive several temporary gauze wicks for drainage during the 
first few days. Counteropenings maybe needed if one is not 
sure of the aseptic condition of the wound. They do no harm 
and may prove safety-valves against latent infection. Before 




leaving the wound it should be thoroughly douched with boiled 
water. An aseptic dressing is applied, and the leg is immobilized 
by the posterior wire and side splints (see Figs. 523, 524) or is put 
up immediately in a plaster-of-Taris splint. If the plaster- of- Paris 
splint is used, a window should be cut in it, through which the 
wound may he dressed. 

Case of a Fracture of the Leg aft«r the Permanent Dress- 
ing has been Applied. — All fractures of the leg will be placed, 
sooner or later, in the fixed plasler-of- Paris splint. One week 




look blue and be swollen. As the patient becomes accustomeci 
to these conditions, which arc in themselves harmless, he will be 
able to ignore tlicm ; tliey will grow less anti less troublesome, 
and eventually disapjwar. At the end of four or five weeks the 



i 



1 


374 FRACTURES OP THE LEG 

fractureshoiild be found firmly united. Alighter plaster splint may 
De applied, extending only to the knee-joint, and allowing flexion 
of the knee. This thin plaster splint should be split, so as to be 
removable. After about four weeks the leg should then receive 
a daily bath and massage, with active and passive motion to the 
Icnee-joint. At about the eighth week the protecting splint may 
be removed, a flannel bandage from the toes to the knee substi- 
tuted, and the patient be allowed to touch the foot to the floor 
iiearing a little weight. A.s soon as the pla.ster is removed arc 
the bandage substituted, a shoe, preferably laced, should be 
worn on that foot. From the tenth to the twelfth week 


1 




^^^ ^PS 

^ ^-^ 






FiK-530.-Ca5c: Optii Pmi's ncturc. Wound in suft pins ai.d pioiiuding libia lo be srtn 

after the injury the patient should be walking with a cane. 
According to present methods, a fractured leg would require 
from three to five months of treatment before restoration to 
normal function is completed. 

The after-care of a case of fracture of the leg is attended 
with no little anxiety on the part of the surgeon. The general 
lealth of the patient is a matter of considerable concern. The 
OSS of e-vercise entailed by the cramped and unnatural position 
causes loss of appetite, headache, constipation, dyspeptic ills, 
etc. The pain through the whole limb, due undoubtedly to the 
sprain and wrenching at the time of [he injurj'. the aching at 
night at the scat of the fracture, combine to render the patient 


J 



TREATMENT 



375 



thoroughly uncomfortable, unhappy, and even mclanchuly. Pres- 
sure spots will appear about the most carefully applied bandage, 
and they must receive attention. Itching of the skin inside the 
sphnts i^ sometimes almost unendurable. To every patient daily 




general and local massage and bathing will be found to be ot 
unspeakable comfort. The average hospital patient is far less 
sensitive to all the petty annoyances of an immovable and closely 

fitting dressing than is the private patient. 



376 FRACTURES OF THE LEG 

The Pr<^nosia. — In children and young people the n 
time is consumed by the process of repair. The restoration of 
the leg to its normal function is more rapid than in the cases of 
adults, and there are fewer complications. In adults a chronic 
arthritis may appear in the neighboring knee- or ankle-joints. 
Swelling of the leg and ankle may persist for some time. Non- 
union of the bones may result, and necessitate operative meas- 
ures (see Fig. 525). If the fracture is oblique, shortening may 
occur even after union takes place if the unsupported leg is used 
too soon and too much. If the wound of an open fracture heals 




quickly 
place :., 
unite 11 
of the 

seal of 
m..iulis 
may for 
tunc (~ 
a„kle-j. 



, ajicl there is little comminution of bone, repair will take 
■; in a closed fracture. Otherwise, an open fracture will 
lore sli>wly than a closed fracture. Persistent swelling 
log, particularly about the ankle, is a.ssociated with the 
sccncc from an open fracture. Necrosis of bone at the 
fractvirc may occur in cases of open fracture even many 
or j'cars afuT the original iiijurj'. Abscesses and sinuses 
in, nircossitating operation for the removal of the necrosed 
ee I'igs. J3C1. 527). If the fracture is near the knee- or 
)ints. tile prognosis is more uncertain than if the fracture 



AFTER TKEATMENT 377 

is at the center of tlie shaft. A comminuted fracture is more 
likely to be longer in uniting and to give rise to trouble after 
repair than is a single transverse fracture. 

Results after Fracture of the Leg. — Of value in this con- 
nection are the results following fracture of the leg in thirty-five 
cases treated at the Massachusetts General Hospilal, and exam- 
ined one and a half to ten years after the accident. In the de- 




tailed report of these cases the exact lesion and its seat will be 
stated. In thirteen cases — in ten of which the age was forty-two, 
the rest under thirty — the result reported was that the injured 
leg was "as good as the other leg." In twenty-two cases the 
result was a leg permanently impaired in some particular. Some 
cases had flat-foot, deformity of the leg. limited motion at the 
knee-joint, lameness, necrosis of bone, pain in the fracture when 
the weather was damp. Other cases had pain in the leg upon 



378 FRACTURES OF THE LEG 

Standing, stiffness of the ankle, pain upon stepping on uneven 
surfaces, weakness of the leg, swelling of the leg and foot, cramps 
at night in the calf of the leg. or some combination of these 
symptoms. 

Thrombosis and Embolism. — Thrombosis of the veins about 
a fracture, and particularly about a fracture in which there is 
some laceration of the soft parts, is not at all uncommon. At 
times, and rather more frequently than is generally supposed, 
emboli are detached from these thrombi and cause almost im- 
mediate death, with symptoms of pulmonary embolism — namely, 
a sudden cyanosis and great difficulty in breathing associated 
with intense precordial distress. , 




Thrombosis of the veins of the leg or thigh is undoubtedly 
one of the causes of the great edema seen after fracture ol 
those parts. 

Refracture of the Bones of the Lower Extremity. — It is not 

an uncommon c.\pcrioncc to find that a patient with a fracture 
of llic tliij^li, !c<;, or patella rcfractures the partially united bone. 
This rofracturc is due to citlier muscular violence or a slight fall. 
There i-i 'nilinarily little displacement of the fragments. The cal- 
lus of the orJLiiiial injury holds the bones quite securely. The 
leg i< usually bent at the seat of tlie fracture. Refracture is, 
llierelbre, practically a fracture of callus. This accident has 
evi ti ncciirreci while the patient is wearing a protective splint of 



POTTS FRACTURE 



379 



plaster-of- Paris. Union in these cases is much more rapid than 
after the original injury. About one-half the time required for 
union of the original fracture is necessary for union of the re- 
fracture. The patient may, therefore, be much encouraged, for 
though the accident of refracture is a disheartening one, yet he 
will not be obliged to look forward to a long confinement. 




POTT'S FRACTURE 
Anatomy. — The anatomical relations of the lower ends of 
the fibula and tibia and the astragalus and os calcis should be 
kept constantly in mind. The os calcis and astragalus are held 
firmly together, forming the posterior portion of the foot. The 
astragalus rests mortise-like between the internal and external 
malleoli (see Fig. 528). The strength of the inferior tibiofibular 



^80 FRACTURES OF THE LEG 

articulation depends upon the strong inferior tibiofibular liga- 
ments, particularly upon the interosseous ligament. 

By Pott's fracture of the ankle is understood the injury caused 
by forcible eversion and abduction of the foot upon the leg. The 
lesions which may be present in this fracture are a rupture of the 
internal lateral ligament, a fracture of the tip of the internal 
malleolus, a separation of the lower tibiofibular articulation, an 
oblique fracture of the fibula two or three inches above the tip 
of the external malleolus, a fracture of the outer edge of the 




iiiiK). 



lower end of the tibia. Ordinarily, the mechanism of the frac- 
ture is somewli.'it as follows : As the foot is abducted, the strain 
is felt at the internal lateral ligament and at the inferior tibio- 
fibular interosseous ligament, and these give way. If the force 
cunlinuis. the fibula breaks (sec Kig. 529"). If the force still 
ontinucs, the internal malleolus is pushed through the skin. 
anil an open fracture results (see Fig. 530). If the internal 
lateral lig^mnjnt holds against this lateral force, the tip of the 
internal nlalle^Ul^ may be pulled off. 



pott's PRACTUKE 



381 



Symptoms. — ^The ankle presents a very constant appear- 
ance after tliis fracture. A traumatic synovitis exists. Great 
swelling appears, at first chiefly upon the inner side of the ankle. 
The ankle-joint becomes distended with blood and serum. All 
the natural hollows about the joint are obliterated. The foot is 
everted, appearing to have been pushed bodily outward. The 
internal malleolus is unduly prominent. Some of thh promi- 
nence is masked by the swelling. The bony coiinections and 
natural support of the foot having been removed, the foot drops 




backward, partly because of the pull of the calf-muscks but 
chiefly because of its own weight (sec Figs. 531, 532). The 
deformity, therefore, is a double one. a lateral sliding of the fiml 
outward and an antgropostcnor dropping of the foot backward. 
The malleoli arc .spread apart : the measured distance between 
them is increased over the normal. Kiljatiiin cio.se above the 
anterior articular edge of the tibia and the ailr.igaius nveals ten- 
derness over the ruptured tibiofibular ligament. The biickward 
displacement is best measured by the length of the line from the 



382 FRACTURES OF THE LEG 

front of the ankle to the cleft between the first and second toes 
(see Fig. 533). This line will be found shortened upon the 
injured side. There is tenderness over the fracture of the fibula. 
If the internal malleolus is fractured, the sharp ridge at the broken 
edge can be distinctly felt. Grasping the posterior part of the 
foot firmly with the whole hand while the other hand steadies 
the lower leg just above the ankle, abnormal lateral mobility of 
the foot may be detected (see Fig. 534). The foot will be felt 
to move inward to its natural position. The moment inward 
pressure is removed the foot will be seen and felt to slump out- 
ward again. 



Diaphy«l« of fibula. — 



i- 539.~Notin*kRnklc-j°'"l< thowlng cpiphyici («nlCTOpotLCTi< 




Figures 535-538 inclusive illustrate a reversed Pott's de- 
formity, the foot having moved inward instead of outward as 
well as having fallen backward. 

Treatment. — The indications for treatment are to place the 

parts in their normal relations, and to maintain them .so until 
repair is completed, guarding against both the lateral and the 
posterior deformities. If for any reason, such as the presence 
of very great .swelling of the ankle, it is cx|Tedient to delay re- 
duction, the le^ should be placed temporarily in a pillow and 
side splints (see l-'i;,'s. 504, 505. 506). An anesthetic should 
always be administered before the reduction of this fracture. 




PlR- S«a.— Poll'* fraclure ( iDUropiHlcrior view). Notice illdinE of ailrBK>ius oulwlrt 
TncturcoriiiiemilnallMiliii. Friclurc of fibuU. Exlrinw dcloinilly (X-ray iraclnit). 

/ 




Sami mi figure MoO'X 



384 



FRACTURES OF THE LEG 



The reduction is thus rendered painless and, through relaxation 
of the muscles, is made far easier. The principles of the old 
Dupuytren splint are the ones to be applied in the reduction of 



Fracture of internal 
malleolus. 



Fig. 542. — Poll's fracture. Almos 




Fracture of fibula. 



n 



o displacement. Compare with figure 540 (Massachusrtts 



General Hospital, 828. X-ray tracing). 



Fiaclurcof fibula. — 




Aslrai^aUis. 4 \ 3 



— I'n usual space. 

— Internal malleolus. 



FJK- -4.V- l''»tl's (rat tiMc. Noiici- sliding "f astragalus outward. Fractures of internal mal- 
leolus ami filMila f Massacluisells (>cnetal Huspilal. s^H. X-ray tracing). 



lliis i'lMclurc \vliatL'\er tlic apparatus in which the Ic^ is perma- 
nently ])lacc(l. These consist of the makini^ of lateral outward 
pressure n[)()n the internal malleolus, lateral inward pressure upon 



pig- M4— r™','* fracluti, sho' _ 
cntVighlV ptotMbk (X-ny Iracins). 




the fibuli iii<l bul sIIbIil ■liillnR of Iti 
ade ■ rapiure of ihe iiiicrnal lateral liii 





iiHtla Gciiiral HoipiLal, 10R4. X-r: 



386 . FRACTURES OF THE LEG 

the foot, and,a forward lift upon the posterior part of the foot or 
heel. The practitioner may very properly use the Diipuytren 
splint. It is thought to be uncomfortable, but it is not if prop- 
erly applied. It is VL-ry efficient in liolding the fracture reduced. 
The Dupuytren Splint. — This is a board from one-quarter to 
one-half of an inch thick, lon_[j enough to extend from the middle 







of the thigh to six inches below the sole of the foot, and as wide 
as the calf of the leg from front to back (^ee Fig. 547). At its 
lower or fool end it is serrated with tiiree or four teeth, as seen in 
the illustration. It is jiadded with folded sheets, so that when it 
is applied to the inner surface of the limb, the padding extends to 
just above the level of the internal malleolus, the serrated end of 



pott's fracture _ 387 

the splint project! ng'six inches below the sole of the foot. The pad- 
ding, as seen in the illustration, is so thick at the lower end over the 
internal malleolus that sufHcient room is left for inversion and rota- 
tion of the foot upon its anteroposterior axis without its impinging 
upon the splint in the least. Tlie splint is held in place by straps 




and buckles : one is placed above the ankle, one above the knee. 
and a third is placed at the upper end of the splint. For the 
proper application of the splint an assistant is needed. The splint 
is applied while the leg rests upon the bed. An assistant steadies 
tile splint and the leg so that they both project clear of the foot 



388 FRACTURES OF THE LEG 

of the bed. A roller bandage is then' applied in circular turns 
about the ankle and splint from the splint toward the leg. After 
two circular turns are made, the assistant adducts and inverts the 
ankle and foot, and this position is held by the third turn of the 
bandage, which is passed around the forward part of the foot and 
over one of the serrations of the sphnt (see Fig. 548). In order to 
hold this firmly a turn is then taken around the ankle, A figure 




unpaddtd (dltEram). 



of eight is thus applied for several turns about the foot and ankle, 
crossing the ankle in front of the instep at each turn. Fach suc- 
ceeding turn is caught by the .succeeding .serration of the splint 
At the same time the foot is lifted forward by pressure from be- 
hind, ami this forwiirii lift is maintained by circular turns of the 
bandage. The whole limb is placed upon pillows. Thus, the 
eversicn and posterior dropping of tile foot are corrected. 
This splint forms a go<^d temporary or emergency dressing 



TREATMENT OF POTT*S FRACTURE 389 

for Pott's fracture. This dressing corrects the eversion, but 
there is great danger that the foot may slump backward 
unless most carefully watched. This failure to hold the pos- 
terior displacement corrected is the defect of the Dupuytren 
splint. 

The Posterior Wire Splint with Curved Foot-piece (see 
Figs. 549, 550, 551). — ^The posterior wire splint extending to 
the middle of the thigh is another apparatus used in treating 
Pott's fracture. The foot-piece should be twisted at the ankle, 
so as to hold the foot when inverted (see Fig. 549). The splint 
is covered and padded in the usual way (see p. 360). The 
patient is anesthetized. The leg is placed upon the splint. The 
foot Js strongly inverted by great lateral pressure put upon the 




Fig. 551. — Pott's fracture. Cabot posterior wire splint, adapted to the adducting of the 
foot. See figure 517 for method of slingingfoot and preventing its backward displacement 
(diagram). 



posterior part of the foot. This inversion of the foot can not be 
made too strongly, for the deformity can not be overcorrected. 
The position of extreme inversion is not a painful one to maintain. 
Ordinarily, the lateral pressure applied is too slight entirely to 
correct the deformity. The foot is held to the inverted foot-piece 
by straps of adhesive plaster, pads, and side splints (see Fig. 550). 
A pad is applied to the sole of the foot, and so placed as to main- 
tain the long anteroposterior arch of the foot. It is found that 
if this is not done, there is considerable flattening of this arch 
upon recovery. The forward lift upon the foot is made and 
maintained by proper padding posteriorly to the lower leg and 
just above the heel (see Fig. 551). The lift may be reinforced 
by smoothly applied strips of adhesive plaster placed laterally on 



390 



FKACTLRES OF THE LEG 



the foot and carried under the heel and up and over the end of 
the foot-piece. These adhesive-plaster strips serve as a sling for 
the foot. There is one other way to avoid pressure upon the 
point of the heel, and that is by placing beneath the heel a ring 
of sheet wadding covered with a tightly wound bandage (see 
F'S' 5^7)- These methods of protecting the heel from pressure 
may all be used at one time to advantage. The side splints are 



a 



applied with great care, being so padded as to maintain the out- 
ward pressure upon the inner surface of the lower end of the tibia, 
and the inward pressure upon the outer surface of the foot. Very 
great care must be exercised that there is no recurrence of the 
deformity. Frequent readjustments are necessary. 

The Lateral and Posterior PI aster-of- Paris Splints (Stim- 
son's Splint). — Thi: poitfrior splint (see Fig. 552) extends from 



391 

the toes along the sole of the foot around the back of the heel 
and up the back of the leg to the knee or to the middle of the 
thigh. The lateral splint (see Fig. 553) begins at the external 
malleolus, passes over the dorsum of the foot to the inner side 
under the sole, and upward along the outer side of the leg to the 




same height as the posterior splint. ICach of these splints is 
made of about six or eight strips of washed crinoline, four inches 
wide and long enough to extend from around the foot to the bend 
of the knee or middle of the thigh. The leg is protected by 
roller bandages of sheet wadding. Plaster cream i^ rubbed into 
the crinoline strips one after the oiher until all the .strips have 



392 



FRACTURES OF THE LEG 



been used. Tiie posterior splint is applied first, and held snugly 
by a gauze bandage to tlie leg and foot. Then the remaining 
crinoline strips are likewise covered with plaster cream and 
applied as the lateral splint (see Fig. 554). This is also held 
snugly by a gauze bandage to the leg and foot. During the 
application of the splint and until the plaster-of- Paris has set, 
the foot should be held in a corrected position by an assistant. 
These two plaster-of- Paris splints are preferable to the encircling 
plaster splint, the ordinary "plaster leg," for by their use the 
ankle can be inspected. Less judgment is requisite in its 
application to insure the correction of the deformity than by the 




use of thu ordinary "piaster splint," As tlie swelling subsides 
and the plaster becomes loose, if the splijits are kept tight by 
bandaging, the deformity can not possibly recur. 

Care of the Fracture after the Permanent Dressing is Ap- 
plied. — If the posterior and .side splints arc u.sed : After the 
initial swelling has subsided — /'. c, after the first week — the leg 
may be placed in a plaster-of-Paris splint (circular bandage), and 
tlie piitient allowed up and about with crutches. The plaster 
should be split after application and held in place by straps or a 
bandage. If the Stimson splint is used, the patient may be 
fUIowed III) and about \\iih crutches at the end uf the first week. 



KEATMENT OF POTTS FRACTURE 



393 



Massage may be applied to the exposed parts of the leg and 
foot daily. At the tliird week all dressings should be removed, 
and gentle massage applied to the wliole leg from toes to 
groin, especial attention being paid to the region of the ankle. 
Massage and gentle passive motion in an anteroposterior direc- 
tion only should be applied at least once or twice daily after the 
second week. All lateral motion is to be avoided. After the 
fifth or sixth week a flannel bandage will be all the support 
needed, althousjh comfort may demand a thin, stiff, retentive 





splint at times. At the end of two months some weight may be 
borne upon the foot. 

Of the three methods of dressing a Pott's fracture the posterior 
and lateral plaster splint of Stimson if by far the simplest, and it 
is efficient in every way. Moreover, it allows of massage being 
instituted early with the least disturbance to the ankle. The 
posterior wire splint is more difficult of application, and needs 
careful watching and frequent readjustment. With the posterior 
wire splint in use the foot or leg is easily accessible to early 
massage by simply loosening the side splints. 



394 FRACTURES OF THE LEG 

Prognosis and Results. — In young adults there should be no 
deformity and almost no permanent disability. In adults there 
will be some stiffness for a time. If the lateral deformity has not 
been completely corrected, a traumatic pronation of the foot will 
result. The longitudinal arch of the foot should be supported 
always by a suitable pad under the instep for at least six months 
following this fracture, whether there is deformity or not (see 
Figs. 555, 556). If there is deformity, it will relieve the pain. 
An insole of leather with a pad stitched to it for support to the 
arch of the foot is often of great service. If there is no pain or 
deformity, it will strengthen the foot until walking is easy again, 
and will prevent deformity appearing. If the anteroposterior 
deformity has not been corrected, pain may be experienced upon 
using the foot. The foot is shortened and dorsal flexion is much 
hindered, so that the gait is decidedly impaired. The patient will 
walk with a more or less stiff ankle. In those cases in which 
there is great deformity associated with extensive laceration of 
the soft parts, the foot and ankle may for many weeks subsequent 
to union be painful, stiff, and swollen. Pain, stiffness, and swell- 
ing increase with the age of the patient — /. e,, the younger the 
patient, the less discomfort will there be following this fracture. 

The Operative Treatment of Old Pott's Fractures. — The in- 
dications for operation will be persisting lateral or backward dis- 
placements. The only method for the relief of these deformities 
is by osteotomy of the tibia and fibula. The results following 
this operation arc satisfactory. 

Open Pott's Fracture (see Fig. 530). — The ankle-joint is 
involved. Two things are to be considered in deciding upon 
the treatment of the injury — the extent of the laceration of the 
soft parts and the amount of injury to the bones. If the lacera- 
tion is so great that the foot is useless, amputation is indicated. 
Amputation is indicated in only two other instances — old age 
and sepsis. If the laceration is not great, and any existing 
dislocation can be reduced, it should be reduced without excision, 
proper drainage being provided, both anteriorly and posteriorly, 
to the joint. If the laceration is not great and reduction of the 
deformity is impossible, then either partial or complete excision 
should be done. If there is great injury to bone, whether the 



OPEN pott's fracture 395 

dislocation can or can not be reduced, a partial or complete ex- 
cision should be done. In every open Pott's fracture, no matter 
how small the wound of the soft parts, in order to insure an 
aseptic wound it should be enlarged sufficiently for thorough 
cleansing with antiseptic solutions in every part. Extreme con- 
servatism should characterize the treatment of recent open Pott's 
fracture. In the large majority of cases treated upon the con- 
servative or expectant plan a useful ankle-joint and foot will 
result. The older the adult patient is, the more radical must be 
the treatment. 



CHAPTER XV 

FRACTURES OF THE BONES OF THE FOOT 

Fracture of the astragalus is caused by a blow on the sole 
of the foot, as in a fall from a height (see Fig. 557). Fracture of 
the OS calcis is often present in the same foot with fracture of the 
astragalus. The ankle-joint may or may not be involved. The 
diagnosis is difficult without the use of the Rontgen ray. Crep- 
itus may be elicited. Great swelling may appear in the region 



Line of fracture. 



^ 



Head and neck 
of astragalus 



Tibia. 

/ 



Cuneiform. Scaphoid. \/ N, 




External 
malleolus. 
— Body of astrag- 
alus. 



- Os calcis. 



^— -i Cuboid. 



Fig- 557* — Fracture of the neck of the astragalus (X-ray tracing). 



of the fracture. It is hi^^hly probable that many cases of sprained 
ankle liave been cases of fracture of the astragalus. If there is 
no displ.icenicnt, treatment will consist in immobilizing the ankle- 
joint with the foot held at a right angle with the leg. As soon 
as the swelling has be^^un to subside, massage may be used to 
aelvantaj^c and convalescence be thus hastened. The most satis- 
factorx' dressing; is a plaster-of- Paris splint extending from the 
toes to below the knee, applied and innnediately split open, so as 

396 



FRACTURE OF THE OS CALCIS 



397 



to form a removable splint. This may be taken off for massage 
and passive motion. Recovery takes place with fair movement 
at the ankle-joint, so that after from two months and a half to 
three months the patient can walk without support. After this 



External malleolus. 



Posterior fragment 
of OS calcis. 

Inferior fragment v 

of OS calcis. \ / 

/ 
/ 
I 
\ 
\ 




Tibia. 



N« Anterior fra^ent 
of OS calcis. 



Fig. 558.— Fracture of the os calcis in the body of the bone (X-ray tracing). 




Line of fracture. 

Fig. 559. — Fracture of the os calcis, almost transversely across the junction of the body and 

neck (X-ray tracing). 



time complete recovery is slow. More or less stiffness and pain 
may exist for four or six months after the accident. 

Fracture of the Os Calcis. — The os calcis is fractured by 
a fall on the sole of the foot, as well as by a powerful contrac- 



398 FRACTURES OF THE BONES OF THE FOOT 

tion of the gastrocnemius muscle and strong tension upon the 
tendo AchilUs. It may be crushed, fractured transversely or 



Fig, 560.— Fraclur* ol th( WH os 




It (Ma. 



, Ifij"- X^i 



luniiitiiiliiially, or a piece may be torn oft" from its posterior por- 
tion near the iiiserlion of the tendo Achillis (see Figs. 558-563 
inclu'-ivei. The symptoms of fracture will be the usual ones of 



TREATMENT 



crepitus, swelling, pain, abnormal mobility. The heel is 
by comparison with its uninjured fellow, to be enlarged. 



seen, 
This 




fracture is sometimes associated with fracture of the astragalus 
(see Fig. 564). The treatment is to immobilize the foot at the 
angle that will best hold the fragments approximately in appo- 



400 



FRACTURES OF THE BONES OP THE FOOT 



sition. Complete plantar flexion of the foot may be needed to 
bring the fragments well into position. The pull upon the tendo 
Achillis is in this position removed from the posterior fragment. 
Massage should be instituted early — during the first week. The 
removable plaster-of-Pari.s dres.sing is the besl form of splint. 
After three weeks the splint should be removed, and a close 
litting flannel bandage applied, with small pads under the mal- 
leoli and on each side of the tendo Achillis. The pads, if applied 
with considerable pressure, will assist very materially in reducing 
the swelling and in restoring form to the ankle. It will be about 
two months before the patient should bear much weight upon the 
foot. After three to four months walking will be comparatively 




■: Po«iei1orv1*w 



easy. It is often the case after fracture of the os calcis and 
also after fracture of the astragalus that there is considerable 
disturbance of the normal mechanism of the foot. A traumatic 
Hat-foot results from the accident. This can be greatly relieved 
by the introduction into the shoe of a leather pad, to raise the 
instep and take the strain off the injured part. The patient may 
find that for a period of .six months or more the wearing of this 
pad is a great support and comfort. The hot-air baking is very 
satisfactory for the relief of the pain and .stiffness felt throughout 
the ankle and foot. The hot-air treatment, combined with mas- 
sage, helps to hasten convalescence. This treatment should be 
used once daily until the pain in the fool has disappeared. 



FRACTURE OF THE METATARSUS 40I 

Open fracture of the astri^alus and os calcis if treated 
antiseptically, recovers with a useful ankle and foot even though 
the ankle-joint is ankylosed. The niediotarsal joint becomes 
more flexible than it ordinarily is. The loss of motion at the 
ankle-joint is compensated for by the mediotarsal joint motion, 
and the individual may walk with hardly a perceptible limp. 
Removal by operation of the fractured bone is attended by good 
functional results, and if the bone is much comminuted or dislo- 
cated, operation is indicated. 



Fis- sds-— MelaUriiis and philangei 




F'g. s66.— Fracture BcriM* 



Fracture of the Metatarsal Bones (see Fig. 565). — This frac- 
ture is caused by direct violence. The first and fifth bones are 
the ones most often broken (see Fig. 566). The symptoms are 
swelling, pain, crepitus, and abnormal mobility. The weight can 
not be borne upon the foot without pain. There is never great 
displacement. In order to avoid trouble in walking after union 
has occurred, it is wise to make the approximation of the frag- 
ments as nearly accurate as possible. A closed or simple frac- 
ture is ordinarily uncomplicated. Union takes place in from 



402 



FRACTURES OF THE BONES OF THE FOOT 



three to four weeks. It will be at least from two to four months 
before the foot can be used without thoitfrht of the injury received. 
If the fracture is open, repair will be slower than after a closed 
fracture. If tiie wound in kept clean and free from infection, no 
complications will arise. If, on the other hand, the wound be- 
comes infected, necrosis of bone, abscess formation, burrowing 
of pus, and great swelling of the foot may occur, all of which 
will greatly delay the healing process. The foot should be 
immobilized by a lateral molded splint of pi aster- of- Paris, This 
should be placed upon either the outer or inner side of the ankle, 
according as the outer or inner metatarsals are broken. The 




splint should extend from the middle of the calf of the leg to the 
tips of the toes. It is held in position by a roller bandage of gauze. 
Fracture of the Phalanges of the Foot. — These fractures 
arc rather unusual, except from a crush of the foot (see Fig. 
567). They are sometimes open. The same general rules of 
treatment apply to fractures of these bones as to fractures of the 
plialaniics of the hand. A simple plantar splint of splint wood, 
pa(itlin;4 cif the toes, and adhi-sive-plastcr straps will be sufficient 
to hold the fracture. If the plantar splint covers the entire sole 
of tile font, it will prove of [jrcat comfort. It is sometimes wise 
to iinniobili/e the ankle-joint b\' the thin plaster side splint, [>ar- 
ticularly if ihuv is swciliiig of the Icf,' and ankle. 



CHAPTER XVI 

ANATOMICAL FACTS REGARDING THE EPIPHYSES 

HiTHEKTO our knowledge of injuries to tJie epiphyses has been 
obtained mainly through chnic.1l and patholc^ical observation. 
This knowledge is only approximately correct. With the assist- 








ance of the Rontgen ray a very great advance is being made in 
the accuracy of our knowledge of the epiphyses. Whereas there 
will, perhaps, always exist differences in the times of the appear- 
ance of thtf ossification centers and the times of union of the 



404 ANATOMICAL FACTS REGARDING THE EPIPHYSES 

epiphyses, the discrepancies in each observer's series of cases 
will grow less and less. 

The importance of an exact knowledge of the epiphyses to 
those having to do with injuries in the neighborhood of joints is 
undoubted. The diagnosis, prognosis, and treatment of joint 
injuries and injuries in the immediate vicinity of joints is far 
more satisfactory than ever before. The book by John Poland 
upon ''Traumatic Separation of the Epipliyses," from which the 
following data are largely taken, marks an era in this branch of 
surgery. Only those facts that are considered especially impor- 
tant for practical everyday use are here mentioned. 



THE DATE OF THE APPEARANCE OF OSSIFICATION IN THE 
CHIEF EPIPHYSES OF THE LONG BONES 

{After Poland) 

f Lower end of femur. 
\ Upper end of tibia. 



At one year < 



Upper end of femur. 

Upper end of humerus. 

. * J t. ir r Lower end of tibia. 

At one and one-hall years < _ , ^ i 

I Lower end of humerus. 

( Lower end of radius. 

At two years < _ , ^ ^. . 

C Lower end of nbula. 

Great trochanter of femur. 



reat tuberosity of humerus. 



» u r ^ 

At three years V 

. , ^ f Upper end of ulna. 

At four years \ ^^ a ( e,\. \ 

y. Upper end of nbula. 

From five to six years \ Upper 

r ^ 

At eight years < y 



end of radius. 



Lower end of ulna, 
esser trochanter of femur. 



After a most exhaustive study of pathological and clinical 
material, both of his own and that of other observers, Poland 
concludes that the order of frequency of separation of the epiphy- 
ses is about as follows : 

1. The upper epiphysis of the humerus. 

2. The lower epiphysis of the femur. 

3. The lower epiphysis of the radius. 

4. The lower epiphysis of the humerus. 

5. The lower epiphysis of the tibia. 

6. The upper epiphysis of the tibia. 



THE LOWER EPIPHYSIS OF THE FEMUR 



405 



The upper epiphysis of the humerus is composed of three 

separate centers of ossification : That for the head, appearing 
at two years ; that for the great tuberosity, appearing at three 
years ; that for the lesser tuberosity, appearing at four years. 
These three centers coalesce to form the upper epiphysis, and 
it unites, at from the twentieth to the twenty-fourth year, to the 
diaphysis of the humerus (see Fig. 568). (For Separation of 
this Epiphysis see p. 128.) 




Fig. 571. — Relation of the capsule of the knee-joint to the lower epiphysis of the femur and the 

upper epiphysis of the tibia (diagram). 






Fig. 572. —Epiphyses at the wrist at seventeen years: a, Ulna; ^, jwslerior surface of the 
radius ; c, anterior surface of the radius (Warren Museum, specimen 447). 



Separation of the upper humeral epiphysis will not necessarily, 
excepting in cases of very great violence, open the shoulder- 
joint, for the capsule is firmly attached to the epiphysis and the 
synovial membrane is loosely attached to the diaphysis (see Fig. 
569). In the adult the epiphyseal line marks the upper limit of 
the surgical neck. 

The lower epiphysis of the femur, the largest epiphysis in 
the body, appears before birth, attains a good size by two years, 



406 ANATOMICAL FACTS REGARDING THE EPIPHYSES 

and unites to the diaphysis at from the twentieth to the twenty- 
third year. (For Separation of this Epiphysis see p. 309.) 

The adductor tubercle is on the diaphysis marking the level 
of the line of the epiphysis upon the inner side of the femur. 
The two heads of the gastrocnemius muscle are attached to both 
the epiphysis and the diaphysis, but chiefly to the diaphysis. 
The plantaris is attached to the diaphysis. Both of these mus- 
cles, in a separation of the epiphysis, are stripped from the shaft 
with the periosteum, and act solely on the detached epiphysis, 
causing it to rotate upon its transverse axis. In separations with- 




FiE' S73. — Rc)ali"'l'.°^ "'' 




out much displacement the knee-joint is not opened. The quad- 
riceps bursa m:iy escape injury (sec Figs. 570, 5?!). 

The lower epiphysis of the radius appears about the second 
year, and unites to the shaft at from the nineteenth to the twen- 
tieth year. (For Separation of this Epiphysis see p. 229.) 

Tin: synovial niccnbrane of the wrist-joint does not touch the 
cpi|)li\'seal line of the radius either anteriorly or posteriorly. It 
takes its origin from the luwer articular margin of the epiphysis. 
Tiic synovial inembranc of the inferior radio-ulnar articulation 
extends above the epiphyseal lines of both the radius and ulna. 
It is loosely connected witii the diaphysis of each bone. In 



THE LOWER EPIPHYSIS OF THE HUMERUS 



407 



epiphyseal separations laceration of the synovial pouch is possi- 
ble, but is not absolutely inevitable (see Fi<js. 572, 573). 

The lower epiphysis of the humerus is formed from three 

sep)arate centers of ossification — viz., the capitellum, which 
appears at three years ; the trochlea, which appears at eleven 
years ; the external epicondyle, which appears at thirteen years 
(see Fig. 574). These three centers coalesce at about the fif- 
teenth year, to form the lower humeral epiphysis. The epiphy- 





Flg. 575. — Tibia showinj^ epiphyses (Warren 
Museum, specimen 417). 



Fig. 576. — Fibula, showing epiphyses 
(Warren Museum specimen). 



sis unites to the diaphysis at about the seventeenth year. The 
epiphysis for the internal epicondyle forms no part of the lower 
humeral epiphysis. It appears at about the fifth year, and joins 
the diaphysis at from the eighteenth to the twentieth year. (For 
Separation of this Epiphysis see p. 171.) 

The synovial membrane at about the fifteenth year and after- 
ward overlaps the epiphyseal line. The epiphyseal line is a little 
higher on the outer side than on the inner. It inclines obliquely 



4o8 



ANATOMICAL FACTS REGARDING THE EPIPHYSES 



s thill 



r internally than 



downward and inward. The epiphysi 
externally. 

The epiphysis of the lower end of the tibia appears about 
the second year, and unites to the diaphysis about the eighteenth 
or nineteenth year. Neither anteriorly nor posteriorly does the 
synovial membrane come in contact with the epiphyseal line, so 
that, unless great violence is exercised or the epiphysis is frac- 
tured, the ankle-joint is unopened in separation of this epiphysis 
(see Figs. 575, 576). 

The epiphysis of the upper end of the tibia (see Fig. 575) 



IIW 




appears at about the first year, and unites to the shaft at the 
twentieth or twcnty-.seconil year. The synovial membrane is 
quite a little distance from the line of the epiphysis. The epiph- 
yseal line runs quite close to the superior tibiofibular articulation. 
The acromion process of the scapula (see F'ig. 577) presents 
an epiphysis that appears at from the fourteenth to the six- 
teenth year, and unites at from the twenty-second to the twenty- 
fifth year. The epiphysis includes the oval articular facet for the 
clavicle. The coracohumcral and acromioclavicular lii;aments 
are attach«l to it. The epiphysis joins the acromion behind 
the acromioclavicular joint. 



CHAPTER XVII 

THE RONTGEN RAY AND ITS RELATION TO 

FRACTURES 

BY E. A. CODMAN, M.D. 

On January 23, 1896, Rontgen read his announcement of the 
discovery of the X-rays before the Physico-medical Society at 
Wurzburg. The extraordinary news fled over the world in an 
incredibly short time. Within a few months skiagraphs of the 
bones of the hands appeared in every newspaper that could 
afford an illustration, and the reporters indulged their imagina- 
tions and dwelt on the advantages the new discovery would 
bring to medicine and surgery. The strangeness of the subject 
offered an unusually brilliant field for the imaginative and 
humorous, and in consequence it will undoubtedly be years 
before the public is disabused of its first erroneous impressions. 
Perhaps more people err now on the side of incredulity than 
credulity, and are inclined to regard the wonders they heard of 
at first as ** newspaper talk." Medical men are particularly sub- 
ject to this criticism, and there are many who seem to feel a 
disappointment in the results. It is unfortunate that Rontgen's 
original article was not widely published in the first place, for it is 
a model of scientific accuracy, and contains not a single statement 
that has not been substantiated again and again. To those men 
who understood the limitations of the X-ray that this article 
pointed out, the results have not been disappointing. On the 
contrary, the improvements in apparatus and technic have 
enlarged the scope of its use and increased the importance of 
the information it gives us. The X-ray department has become 
a necessity in every large general hospital. 

In discussing the value of Rontgen's discovery in a book on 

the treatment of fractures it has seemed wise to point out some 

of the mistakes that are commonly made in the interpretation of 

409 



4IO THE RONTGEN RAY AND ITS RELATION TO FRACTURES 

skiagraphs. To those who have done practical work with the 
X-rays this chapter will be valueless ; but those who have not 
may find in it some assistance in their effort to learn what real 
value the new science is to this branch of surgery. 

Among other misconceptions the Crooke's tube was supposed 
to emit a very powerful light. It is not a powerful light, but 
merely a faint one of such quality that it is able to penetrate 
substances that ordinary light does not. It is its peculiar 
quality, not its intensity, that enables it to penetrate opaque ob- 
jects. It is invisible to our eyes, but has the quality of causing 
chemical action on a photographic plate or of affecting crystals 
of certain substances so as to make them emit a faint light. A 
sort of sand-paper made of these crystals, finely ground, forms a 
fluorescent screen, or fluoroscope ; and any substance that is 
not easily penetrated by these rays, when placed between the 
source of light and the screen, will cut off the rays and cast a 
shadow on the sand-paper that can be seen on the side away 
from the object. This shadow will be more or less deep, accord- 
ing to whether the substance cuts off more or less rays. Thus, 
iron casts a darker shadow than wood ; bone, a darker shadow 
than flesh. In general the opacity of different substances varies 
directly with their atomic weights. In the same way the sub- 
stance placed between the source of light and a photographic 
plate will cut off some of the rays from the plate. Where these 
are cut off, chemical action does not occur ; where some of the 
rays go through, it occurs slightly ; where the object does not 
interfere at all and the rays strike the plate directly, the action 
is greatest. When the plate is developed, we get a picture of 
the shadow of the object with its most dense parts most deeply 
shaded. 

Many people confuse an X-ray picture with a photograph. 
They take it to be a photograph by X-ray light. It is not a 
photograph, but a shadow-picture, a compound silhouette, a pro- 
jection of the parts of an object. A photograph of the hand is 
made by the liglit rcllccted from the hand to the photographic 
plate, and shows the surface of the skin. A skiagraph of the 
hand is made by the light that has passed through the hand, 
and shows a chart of the different densities of the different con- 



MISTAKES IN INTERPRKTATION OF SKIAGRAPHS 4I 1 

stitLients of the hand, as bone, muscle, fat, and skin. As the 
other parts of the hand are of about equal density and this den- 
sity is much less than that of bone, the bones appear promi- 
nently on the chart. The thickest portions and most dense 
portions of the bone appear more deeply marked than the lighter 
and spongy portions. As every little gradation of density is 
registered, the whole forms a picture. 

As far as we know, the effects of the X-rays are only obtain- 
able in the immediate neighborhood of their source ; that is, a 
small point on the platinum reflector in the Crooke's tube. From 
this point they radiate in all directions, their power gradually 
diminishing until at a distance of about a hundred feet or a little 
more they are not appreciable by any means now at our com- 
mand. Practically, they are only strong enough for skiagraphic 
purposes within a few feet of the tube. 

Since they proceed from a point, and are not approximately 
parallel like the sun^s rays, their shadows are necessarily dis- 
torted. We are all familiar with the distorted shadows thrown 
on the wall by a candle. The same distortion takes place in an 
X-ray picture in a lesser degree. Since the rays proceed from a 
point, all parts of an object can not stand in the same relation to 
that point and the surface of a plate at the same time. The 
least distortion will take place when the object is in contact with 
the plate, and as far from the light as is consistent with obtaining 
sufficient effect to take the picture : that is, to have the rays 
penetrate the less dense portions of the object. Let the dis- 
tance from the point to the plate remain the same. It follows 
that : 

(a) Shadows will be enlarged in proportion to the distance of 
the object from the plate, toward the light. 

(6) Shadows are distorted of any object or part of an object 
not in a perpendicular line from the point of light to the surface 
of the plate, and that distortion takes place in a line drawn from 
the base of such perpendicular through that object or part of 
an object. 

As an illustration of these distortions, we have represented in 
figure 579 the projection of a cubical block of wood (rt). For 



412 THE RONTGES RAV AND ITS 



< FRACTURES 



convenience of drawing, the shadow (d) is represented at an 
angle. The outside square of 6 represents the upper surface of 
the bloclv, while the inner square represents the lower. The 
density of the shadow is greatest at the edges of the lower 
square, for they represent the longest paths of the rays through 
the block. From the consideration of figures 580, 581, 582, 
and 583 the reader will readily observe that any change in the 




lilt of the plane of the plate (Mf;, 581, rt)in tlie shape or density 
of the object, or in the distance of the ])oint of lit,dit (Fig. 583). 
will produce a definite altoration of the shadow or picture. It 
i.-i, therefore, necessary in looking at a skiagraph to know how 
the plane of the plate lay, how far distant the light was, and, in 
general, what the shape and density of the different parts of the 
object were. 



THE INTERPRETATION OF SKIAGRAPHS 



413 



Just as it is true that the shadow of any object increases in 
size as it is moved from the plate toward the light, so also it 




Fig. 580. 



Halt 




TlaJU 



TiaXt 



Fig. 581. 



is true that the density of the shadow decreases as its size in- 
creases. Each object that is translucent to the X-rays seems 
tQ have the ability to cut off a certain amount of X-ray light. 



414 THE RONTGEN RAY AND ITS RELATION TO FRACTURES 

In Other words, it contains a certain amount of shadow-casting 
material. As it is moved from the plate toward the liglit its 
shadow increases in size, but diminishes in density, since only a 
certain amount of light can be obstructed by that object. 

Putting it in another way, we see that the object x y (Fig- 
580) in the angle a b c interferes with three times as much 
light as if in the position of a d c, but since it can only cut off 
a certain quantity of rays in either position, the shadow in rf ^ 
will be darker, though smaller than 6 c. Of course, \i x y 





were not penetrated at all by the rays, the shadow would be at 
a maximum in both cases. \n a b c there are three times as 
many rays to go through, but x y can onlj' subtract a certain 
number. It can subtract that number from « i^ c where there 
will be a smaller remainder and hence a deeper shadow. This 
i.s an c-ijiccially important point to keep in mind, for the range of 
variation <if den.sity of diflTereiit bones is very small, and a very 
.slight change in position in relation to the plate may make an 
ennruion- ditTcrence in the resulting picture. For example, figure 
5M4, a skiagraph of the knee taken from behind, — /. e, with the 



THE INTERPRETATION OF SKIAIiKAPHS 415 

plate behind, — C shows httle or no sign of the patella. While 
with the plate in front {/^) and the tube behind, the outline of the 
patella is distinguishable through the shadow of the femur. 
This is the more decided if the tube is brought quite near to the 
back of the knee (A), for then the size of the shadow of the 
femur is increased and its density diminished, while that of the 
patella remains nearly the same in both size and density. 

Another point that, though simple, seems to cause misunder- 
standing is illustrated in figure 583, representing the shadow of 
a section of one of the cylindrical bones. It is intended to show 




why a long bone appears hke a longitudinal section in a skia- 
graph. Though the whole circumference may be of the same 
thickness, the rays that pass through the sides, x~f, meet more 
resistance than those through the center ; hence the medullary 
cavity appears on the plate. 

It is often of great assistance to plot out on paper a projection 
of the salient points of the subject, as in figure 579, at the same 
time bearing in mind that variations occur in density as well as 
in size. We should like to go into the question of the decep- 
tiveness of skiagraphs at greater length, because we regard it 
as of the utmost importance that every physician who uses this 



4l6 THE RONTGEN RAY AND ITS RELATION TO FRACTURES 

means of diagnosis should fully understand the way in which any 
conclusion should be drawn from one of these pictures. Though 
the pictures themselves are inaccurate as pictures of the object, 
they are accurate pictures of the shadows of the different parts 
of the object, and the reasoning of conclusions drawn from them 
should be exact. 

In answer to the question of what help the X-ray has 
been in increasing our knowledge of the pathology and treat- 
ment of fractures, we may mention first the general points 
and then the particular fractures in which we find it to be of 
benefit. Although surgeons have always realized very nearly 
accurately the position of the displaced fragments in the common 
fractures, there can be no doubt that the production of pictures of 
the exact condition in individual cases gives more reliable infor- 
mation of the condition and relation of the broken ends than can 
possibly be obtained by palpation. A more definite knowledge 
of the pathology brings greater exactness of treatment. When 
the splints are applied, it can be ascertained whether the position 
is good without removing the bandages. Little details that 
otherwise would escape notice are brought out. The patient is 
spared painful manipulation or etherization and the bruising and 
laceration of the tissues from unnecessary handling. The ques- 
tion of a cutting operation to reduce otherwise intractable frag- 
ments may be decided by an exact knowledge of the positions 
of the parts. This subject of the advisability of interference by 
making a simple fracture compound is one that is attracting 
more and more attention, and will lead to its being made the rule 
in cases where a perfect result can not be expected by the simple 
method. When asepsis can be practised, there is little danger of 
making an incision, and the time saved in cases where approxi- 
mation of the fragments is prevented by loose bits of bone or soft 
parts is well worth this slight risk. 

At present we find the X-rays of more assistance in the 
study of the pathology of fractures than we do in their treat- 
ment. r\^r thouirh we bcliev^e that in each individual case of 
fracture a skiagraph is of decided assistance, yet it must be con- 
fessed that the cases where it leads us to modify the treatment 
to any considerable extent are few in number. A diagnosis 



ITS PRACTICAL VALUE 417 

of fracture without skiagraphs is always open to doubt, while 
with a careful X-ray examination there is seldom a doubt. We 
appreciate the X-ray, too, when, after applying our splints, 
even if plaster, we assure ourselves of the correct alinement of 
the bones. 

As a means of demonstrating to students the pathology of 
fractures, a series of lantern-slides is of the greatest assistance. 
The knowledge that the pictures are of actual cases and not 
theoretic diagrams gives a practical interest that is akin to clin- 
ical instruction. The plates when shown at the same time as the 
case at a hospital clinic also serve to illustrate the pathology and 
indications for treatment. 

A not unimportant result of the use of Rontgen's discovery is 
the exactness it offers as a method of record in the rarer frac- 
tures. Heretofore statistics on the uncommon forms of fracture 
have always been open to the doubt of mistaken diagnoses, and 
we have been dependent on the chance of securing postmor- 
tem specimens in order to obtain accuracy. In future the 
recorded cases of this kind can be illustrated by skiagraphs, 
and we may look forward to not only greater accuracy, but to a 
much greater number of cases that were formerly considered 
rare. Every large hospital will be able to turn to its records 
and say definitely in what percentage any given fracture occurred. 
At the same time, each individual case has the benefit of a 
definite record, and the result can be compared with the extent 
of injury. 

The reader will now ask in what forms of fracture can we 
say the X-ray is of great assistance. In general, those bones 
that can be brought near the plate or that are not over- 
shadowed by other bones give the most satisfactory skiagraphs. 
Therefore, little can be expected of skiagraphs of the bones of 
the head or vertebrae, while those of the extremities come out 
with great precision. The pelvic and shoulder-bones stand 
midway between these, but with a good apparatus and care in 
the choice of the relative positions of the plate, tube, and the 
particular portion of the bone to be taken, we may expect a def- 
inite picture. Even in the case of the skull and vertebrae we 

occasionally find a skiagraph of advantage. The entire contour 
27 



41 8 THE RONTGEN RAY AND ITS RELATION TO FRACTURES 

of the lower jaw can be easily investigated ; the nasal, alveolar, 
and mastoid processes and malar bones come out sharply ; the 
cervical vertebrae, both from behind and from the side, can be 
brought out with great detail, while the dorsal and lumbar, 
though not appearing clearly, sometimes show the rough out- 
lines of bodies and articular, transverse, and spinous processes. 
Any particular portion of any particular rib, except the necks, can 
be taken with great accuracy, since the plate can be laid almost 
directly upon it. The clavicle, too, comes out clearly. The 
sternum is too much overshadowed by the dense dorsal vertebrae 
to show definite outlines. 

Fractures in the shoulder-joint are often impossible to recog- 
nize without the X-ray, particularly in those cases where the 
swelling and effusion about the joint prevent manipulation. Frac- 
tures of the tuberosities of the humerus, of the surgical and ana- 
tomical necks, can be differentiated with great certainty. When 
separation and dislocation of the epiphysis have occurred, we may 
decide the question of operation ; and the same question may be 
answered in those puzzling cases in which fracture of the neck has 
occurred with dislocation. Separation of the tuberosities we now 
find is a much more common accident than we had supposed. 
Even in breaks of the shaft of the humerus and the other long 
bones we gain much information. The extent, direction, and 
plane of cleavage, with the exact amount of displacement, are 
guides for the application of padding and splints. It is in frac- 
tures of the long bones particularly that a second series of skia- 
graphs with the splints in position is of value. The amount 
of shortening is shown more accurately than by measuring the 
landmarks, for the overlapping can be distinctly seen. If neces- 
sary, the approximation of the fragments can be aided by proper 
pads. 

It is not out of place here to refer again to the question of 
distortion, for in these cases one must remember that not only 
may the bones be magnified, but also the interspace between 
them. Two or more pictures must be taken, for a view from the 
side will often show a displacement that is not brought out in 
the shadow from in front or behind. The fluoroscope is particu- 
larly useful in this sort of work, for, while it does not give the 



ITS PRACTICAL VALUE 4I9 

detail that can be seen in a plate, it is clear enough to assure 
one of the alinement of the parts and avoids the trouble of tak- 
ing and developing the plates. In general work, however, we 
place less reliance on the fluoroscope and rely on the skiagraph. 
As will be pointed out later, the use of the fluoroscope, also, is 
not without danger of dermatitis. 

It is in injuries about the elbow-joint that we must be more 
than ever upon our guard to avoid false conclusions from the 
distortions that we have endeavored to point out. It will be 
most useful to any practitioner who intends to do X-ray work to 
take a series of skiagraphs of the normal elbow-joint from dif- 
ferent positions and in different positions, and to study most 
carefully the projections of the parts in each. Such a series of 
injuries occur in this region that the diagnoses are most difficult, 
and the skiagraph correctly interpreted is of the greatest help. 
Cases that formerly appeared in hospital records as ** injury to 
elbow" are now divided into "fractures of head of radius," 
** neck of radius," '* separation of coronoid process," etc. A 
feature which is now thoroughly brought out is the common 
occurrence of fracture with dislocation. Injuries to the elbow 
are particularly puzzling in children, since the ossification of the 
epiphyses is found in different stages, and the cartilaginous por- 
tions do not show in our plates. We may expect better results 
in this field when, by study and experience, we learn more of the 
time and mode of formation of the epiphyses. 

In the wrist Rontgen's discovery has taught us much. We 
find in the fracture of the lower end of the radius a variety of 
types. Breaking of the styloid of the ulna is found to exist 
much more often than was supposed. The styloid of the ulna 
was fractured in 80 per cent, of 140 cases of Colles' fracture. 
Fracture of the scaphoid is also not uncommon both alone and 
in conjunction with Colles' fracture. Fractures of the semilunar 
and OS magnum are also reported. The metacarpals and phal- 
anges offer a less interesting field, but in the former, when impac- 
tion into the distal extremity has occurred and it is impossible 
to obtain crepitus or mobility, a skiagraph shows clearly the 
condition. 

Improvements in apparatus and technique have enabled us to 



420 THE RONTGEN RAY AND ITS RELATION TO FRACTURES 

get, as a rule, clear pictures of the upper extremity of the femur 
when normal or recently broken. When diseased or sur- 
rounded by much inflammatory thickening or calcareous deposit, 
the outlines are blurred and unsatisfactory, but yet throw light 
on the diagnosis. There are often puzzling cases when fracture, 
dislocation, tuberculosis, and coxa vara all have to be considered, 
and in which a skiagraph is of the greatest assistance. Any 
portion of the shaft of the femur can be taken, and, since portable 
X-ray apparatus have come into use, the picture maybe obtained 
without disturbing the patient or his dressings. Of the knee 
we get very clear plates. Of the method of taking the patella 
we have already spoken. We can compare the results of the 
traction treatment with those of suture and wiring. It is of 
assistance in determining whether the fragments are not too 
much shattered to admit of wiring. 

In injuries of the lower leg we may apply what has already 
been said of the other long bones, and in addition mention a 
case in which a fragment from the external malleolus lodged back 
of the astragalus under the tendo Achillis. In the foot, as in the 
wrist, the X-ray has taught us much. Numerous cases of breaks 
in the os calcis, astragalus, and scaphoid have been reported, 
and, though fractures of the other tarsal bones have not fallen 
within our experience, their occurrence might easily be recog- 
nized. Gocht points out that many swollen feet of uncertain 
diagnosis prove to be fractures of the metatarsals. He also 
reports fracture of one of the sesamoid bones of the great 
toe. 

It is commonly said that the X-ray is dangerous to the patient 
and burns the skin and destroys the hair. This is true as a 
possibility, but nowadays is only to be feared in connection with 
gross ignorance and carelessness. It is a fact that Crooke's tube 
in action is capable of causing an effect on the tissues similar in 
many respects to a burn. But this action does not take place 
unless the tissues are exposed to the tube for a considerable 
period of time and at a very short distance : For instance, eight 
inches from the tube for an exposure of five minutes we should 
consider perfectly safe ; one inch from the tube and five minutes, 
dangerous. Probably the skins of different people vary in 



THE LOCAL EFFECT OF THE RONTGEN RAY 42 1 

susceptibility to this influence, but we doubt if injury ever 
occurred unless the tube was within a foot of the patient. 

Danger to the hands of the operator of the apparatus is quite 
another matter, for repeated exposure may produce the same 
condition. The most severe cases occur when, in the use of the 
fluoroscope, the operator puts his hand near the tube, either to 
hold the patient's limb in place or to demonstrate the bones of 
his hand to an audience. Physicians who are called upon to 
use the fluoroscope often should wear rubber gloves to protect 
the hands, or cover the tube with a grounded aluminium screen. 
Most of the recorded cases of severe injury took place when the 
new light was first used, and experience had not pointed out 
these cautions. To-day, with our improved apparatus, the 
penetration and definition render a closer approach to the tube 
than twelve inches unnecessary. The cause of these burns has 
been a subject of much discussion, and it may still be considered 
an open question. There are many who believe it to be due to 
an electrostatic effect, while others, among whom is Professor 
Elihu Thomson, aflRrm that the Rontgen rays themselves are 
responsible. Professor Thomson certainly should be an au- 
thority on this point, for he has not only the advantages of 
his electrical knowledge, but also of experimental experience. 
The following is a quotation from a personal letter from him in 
November, 1896, describing a somewhat heroic experiment. 

** Hearing of the effects of the X-rays on the tissues, especially 
on the skin, I determined to find out what foundation the state- 
ments had by exposing a single finger to the rays. I used for 
this the little finger of the left hand, exposing it close up to the 
tube, about one and one-quarter inches from the platinum 
source of the rays, for one-half an hour. For about nine days 
very little effect was noticed ; then the finger became hyper- 
sensitive to the touch, dark red, somewhat swollen, stiff"; and 
soon after, the finger began to blister. The blister started at 
the maximum point of action of the rays, spread in all directions 
covering the area exposed, so that now the epidermis is nearly 
detached from the skin ; underneath and between the two there 
is a formation of purulent matter that escapes through a crack 
in the blister. It will be three weeks to-day since the exposure 



422 THE RO.VTGEX RAY AND ITS RELATION* TO FR.\CTURES 

was made, and the healing process seems to be as slow as the 
ori<nnaI coming on of the trouble." 

Four days later : ** The whole epidermis is off the back of the 
finger and off the sides of it also, while the tissue even under the 
nail is whitened and probably dead, ready to be cast off. The 
back of the finger for a considerable extent, where it received 
the strongest radiation, is raw and will not recover its epidermis, 
apparently, except from the sides of the wound." 

Not entirely satisfied with this experiment. Professor Thom- 
son shortly afterward repeated it on another finger, which he 
covered with some aluminium foil in such a ^i-ay as to con\'ince 
him that the tissue, while still exposed to the X-ray, was 
shielded from the brush dischai^e. As he obtained the same 
result, he concluded in favor of the Rontgen ray itself. In a 
recent article on the subject he shows that this effect is due to 
those of the rays that are less readily transmitted by the tissues 
and are less valuable for skiagraphic purposes. 

This quotation is made not only from its value as an experi- 
ment, but also because it is so clear a description of this form 
of dermatitis. The long period before the effects became e\'ident 
is quite characteristic, although in many cases they have ap- 
peared sooner. It seems probable that the direct effect is on 
the vasomotor or trophic nerve supply, which eventually affects 
the nutrition of the part. 

This chapter has been mainly devoted to warnings of the 
dangers of the Rontgen ray, and may in a measure discourage 
practitioners from its use. It should be stated, however, that 
when the limits of error are kept clearly in mind, the actual 
value of the discovery to surgical science is very great. When 
there is doubt of the detailed diagnosis of a fracture, no physi- 
cian has done his full duty by his patient if he can command 
skiagraphic examination and has not used it. This is particu- 
larly true in medicolegal cases where there is a question of 
liability. 



medicolegal relations of x-rays 423 

Conclusions Expressing the Views of The American Sur- 
gical Association upon the Medicolegal Relations of 
X-rays; Adopted in May, 1900. 

1. The routine employment of the X-ray in cases of fracture 
is not at present (1900) of sufficient definite advantage to justify 
the teaching that it should be used in every case. If the sur- 
geon is in doubt as to his diagnosis, he should make use of this 
as of every other available means to add to his knowledge of the 
case, but even then he should not forget the grave possibilities of 
misinterpretation. There is evidence that in competent hands 
plates may be made that will fail to reveal the presence of exist- 
ing fractures or will appear to show a fracture that does not 
exist. 

2. In the regions of the base of the skull, the spine, the pelvis, 
and the hips, the X-ray results have not as yet been thoroughly 
satisfactory, although good skiagraphs have been made of lesions 
in the last three localities. On account of the rarity of such 
skiagraphs of these parts, special caution should be observed, 
when they are affected, in basing upon X-ray testimony any 
important diagnosis or line of treatment. 

3. As to questions of deformity, skiagraphs alone, without 
expert surgical interpretation, are generally useless and frequently 
misleading. The appearance of deformity may be produced in 
any normal bone, and existing deformity may be grossly exag- 
gerated. 

4. It is not possible to distinguish after recent fractures 
between cases in which perfectly satisfactory callus has formed 
and cases which will go on to nonunion. Neither can fibrous 
union be distinguished from union by callus in which lime-salts 
have not yet been deposited. There is abundant evidence to 
show that the use of the X-ray in these cases should be regarded 
as merely the adjunct to other surgical methods, and that its 
testimony is especially fallible. 

5. The evidence as to X-ray burns seems to show that in the 
majority of cases they are easily and certainly preventable. The 
essential cause is still a matter of dispute. It seems not unlikely, 
when the strange susceptibilities due to idiosyncrasy are remem- 



424 THE ROXTGEN RAY AND ITS RELATION TO FRACTURES 

bered, that in a small number of cases it may make a given 
individual especially liable to this form of injury. 

6. In the recognition of foreign bodies the skiagraph is of the 
very greatest value ; in their localization it has occasionally 
failed. The mistakes recorded in the former case should easily 
have been avoided ; in the latter, they are becoming less and less 
frequent, and by the employment of accurate mathematical 
methods can probably in time be eliminated. In the mean while, 
however, the surgeon who bases an important operation on the 
localization of a foreign body buried in the tissues should remem- 
ber the possibility of error that still exists. 

7. It has not seemed worth while to attempt a review of the 
situation from the strictly legal standpoint. It would vary in 
different States and with different judges to interpret the law. 
The evidence shows, however, that in many places and under 
many differing circumstances the skiagraph will undoubtedly be 
a factor in medicolegal cases. 

8. The technicalities of its production, the manipulation of 
the apparatus, etc., are already in the hands of specialists, and 
with that subject also it has not seemed worth while to deal. 
But it is earnestly recommended that the surgeon should so 
familiarize himself with the appearance of skiagraphs, with their 
distortions, with the relative values of their shadows and out- 
lines, as to be himself the judge of their teachings, and not to 
depend upon the interpretation of others, who may lack the wide 
experience with surgical injury and disease necessary for the 
correct reading of these pictures. 



CHAPTER XVIII 
THE EMPLOYMENT OF PLASTER-OF-PARIS 

Many of the fractures of the upper and lower extremities may, 
at some period, very properly be treated by the plaster-of- Paris 
splint. 

The plaster-of- Paris should be of the best quality and dry. 
Crinoline is used for bandages. Commercially it is called 
Arrowwanna Crinoline Lining. It is a lining material that is 
coarser meshed than the cheese-cloth used for gauze bandages, 
and is also stiffer than cheese-cloth. It should be cut into four- 
yard lengths, folded, and stitched together. Crinoline contains 
considerable sizing or glue. This is detrimental to its use as 
a plaster bandage. It should, therefore, be washed of the sizing 
in lukewarm water, thoroughly rinsed, and rough dried. The 
stitching holds the material firmly together during the washing. 
It should then be cut into strips the widths of the desired 
bandages. Three widths are ordinarily useful — namely, widths 
of two inches, three inches, and five and one-half inches. These 
four-yard strips are made into roller bandages. 

Rolling the Plaster. — It is a simple matter to make one's own 
plaster roller bandages. It is possible to purchase plaster ban- 
dages in sealed packages. These are ordinarily made with un- 
washed crinoline and are less desirable. A shallow box or tray 
is needed to hold the plaster. Two persons can roll the bandage 
with facility. *'A" manages the roll of crinoline, straightens it 
as it unwinds, spreads the plaster with a light piece of board, the 
size of the hand, while ** B" draws the crinoline across the tray 
from under the board held by ** A," and rolls up the bandage 
loosely and evenly. ** A " with the board held still and plaster 
heaped upon the bandage behind it, regulates, by more or less 
pressure upon the bandage, the amount of plaster distributed 
over the crinoline. It requires but ten or fifteen minutes to 

425 



L 




I 



430 THE EMPLOVMENT OF PLASTER-OF-PAHIS 

make enough bandages for a plaster splint for the leg or thigii. 
An advantage in making one's own bandages is that they are 
made of the desired width and have the proper amount of 
plaster. They arc fresh and more likely, therefore, to set readily 
upon being wet. If many bandages are made at a time, they 
may be kept in a tin cracker box. If the closed box is put in a 




dry place, these bandages will keep indefinitely. Should the 
plaster become damp, the bandages should be placed in a warm 
oven until dry. It is important in making the plaster rollers to 
put just enough plaster into the bandage and to dislribiitc the 
plaster evenly through the meshes of the crinoline. The proper 
amount of plaster to put into a bandage can only be learned by 



MAKIMG THE PLASTER BANDAf 



431 



experience in making and using the bandages. It is a cunimon 
error to spread the plaster too thickly. The water in whicli the 
bandages are dipped should be lukewarm and of sufficient deptii 
to cover the bandages when set up on end. The water working 
its way into the meshes of the bandage displaces the air in the 
bandage, which is indicated by the bubbles rising to the surface 




of the water. As soon as the bubbles have stop]>ed rising the 
plaster is thoroughly wet throughout the bandage. Table salt, 
two leaspoonfuls to four quarts of water, hastens the setting of 
the plaster. Its use, however, is to be deprecated, because the 
plaster has to be applied too quickly for the best results in 
plaster work, and the brittleness of the plaster resulting from 
the use of salt is undesirable, The plaster bandage should be 



433 



THE EMPIJIYMENT OF PLASTEK-OF-PARIS 



iiftfd from the water carefullj' with both hands holding the two 
ends so as to retain as much plaster as possible within the roll. 
The bandage should then be wrung free from water while the 
hands still grasp its ends. The bandage should be wrung until 
it does not drip. In the application of the plaster splint to frac- 
tures of any part of the body it is important that all deformity 
should be corrected and that the part should be thoroughly 




immobilized. This necessitates the presence of one or two 
assistants. 

In applying a plaster splint with the roller bandage the sur- 
geon should do his work so carefully that he scatters no plaster 
anywhere but upon the splint and in the pail of water. The 
surgeon should work neatly. The patient should be protected 
by a sheet. The floor should be protected by a sheet spread 
under the patient and under the chair of the surgeon. The 
surgeon should remove his coat, roll up his sleeves, and be pro- 
tected from unexpected spattering of plaster by an apron or 
sheet over his body. 



APPLYING THE PLASTER BANDAGE 433 

One tliickness of sheet wadding torn into strips, from three to 
five inches wide, and rolled into roller banda<>es and then applied 
to the limb forms the best protection to the skin in applying the 




^T' 






li 


^.v « 


\ . 


■b 


- ^"- 


£ 



I 



plaster splint. The sheet wadding is purchased al any of the 
dry-goods stores. It may be purchased by the quarter bale or 
by the single siieet. The plaster bandage should be applied to 



43+ Tlie EMPLOVMEYT OF PLASTER -OF- PARIS 

the protected part slowly, deliberately, and accurately. The 
bandage should be applied smoothly, and should have no wrin- 
kles or thick awkward places anywhere. It is well to rub the 
handle as fast as it is laid upon the part with the palm of the 
hand slightly wet to distribute the plaster cream thoroughly and 
evenly. Over bony prominences the bandage should be very 
carefully molded. This will insure a good fit and less likelihood 
of slipping upon change of position. It is well to carry the first 
roll of plaster as far as it will go, one or two layers thick, com- 
pleting the whole splint once, and then to go over it again from 



rg. Plulil-Df-Parii tplinl si'I>I>,^d frnm Ibr to. 
■Dglc With tl>c IcE' T(Mi pailJed lo ftcvcnl cha 



beginning to end. A sufficient number of layers should be ap- 
plied to make a firm enough splint for the support of ihc part 
when the plaster has set. The splint should be as light as is 
compatible with strength. Light splints, if accurately fitted. 
accomplish more good than heavy, ill-filting ones. It is better to 
use too few rolls of plaster bandage rather than so many that a 
heavy and cumbersome splint is made. Immediately after the 
plaster has set, if it is found to be too weak at any spot, an 
additional bandage may be u.'^ed to remforce at that point. 
The part bandaged should be held in perfect position until the 
plaster has set firmly enough to support it. This will ordinarily 



43^ THE EMPLQVMIiNT OF PL;\STER-0F-PAK1S 

occur in about ten or fifteen minutes. The weight of the splint 
may be materially reduced by using tin strips incorporated in the 
layers of the plaster bandage. These strips should be perforated 
by holes so as to offer rough places to catch in tiie plaster 
bandage. The two ends of the splint should be so finished thai 
pressure and consequent deformity can not occur — for instance, 
the plaster of the forearm should stop just short of the bend of 
the elbow. The plaster of the thigh should be so far below the 







perineum and groin as to permit of flexion of the thigh upon 
the trunk without e.\corialing tlie skin of llie groin, The toes 
and fingers should be left uncovered to admit of inspection. 

A great degree of skill is demanded upon the part of the 
sui^eon for the proper application of the plaster-of- Paris splint. 
Plaster-of-I'aris. when us^d for fractured bones, is applied either 
before or after the swelling has taken place: if applied before, 
it constrict-s the seat of fracture, prevents swi_]litig, and may 



.PPLVING THE PLASTER BANDAGE 



cause great pain ; if applied after the swelling has taken place, it 
becomes loose as soon as the swellinj;; of the soft parts subsides, 




and motion of the limb in the splint and of the fragments of the | 
fractured bone oni: upon the other is possible. It is important, 



therefore, to split the plaster soon after it has been applied, and 
thus ubvialc these dangers of too light and loo loose a splint. 
The tightness of the splint should be regulated by straps and a 
b.indage of cheese-cloth. 

The Removal of the Plaster Splint. — The removal of the 
plaster splint is difficult. \o instrument has been devised that 
is more efficient ihan an ordinary sharp jack-knife. If the 
plaster splint is split immediately after its application, — /. c, as 
soon as it is h.irtl, — it will be far easier than if it is cut after it is 




ihi'rouijhly itr)\ A strip of tin an inch wide laid upon the pro- 
twctcil ley ;uul eovvrwl by the plaster in its application will often 
be uf great sen'ic*- upon removing the plaster. The tin will 
serve us a protection to the skin, and the cutting may be done 
nitire quickly und easily. 

After nrmoNnng most of the plaster from his hands the su rgeon 
should \\.i%h h(« ll^ttd^ with a little water and granulated sugar 
or mola^sci. The sugar assists in removing all traces of plaster 
and leaves the skin soft and clean. Bandages of plaster-of- Paris 
AN »o ronitil)' obtained, so efficient, so safe from interference 



THE DEXTRIN BANDAGE 439 

upon the part of the patient, and so easy to apply, that it is 
surprising they are not applied more often than they are. 

The dextrin bandage is much slower in becoming firm than 
the plaster bandage, and is very light and serviceable. It is 
applied exactly as is the plaster-of- Paris bandage. The roller 
bandage of cotton cloth is first unrolled and rerolled in a 
basin containing a watery solution of powdered dextrin. For- 
mula for making the solution of dextrin : Add about four- 
teen ounces of powdered dextrin to a pint of water, boil until 
dissolved, strain, and add one ounce of alcohol. The bandage 
is, therefore, thoroughly saturated with the dextrin solution. 
After covering the part bandaged once, dextrin is painted, 
with a small paint-brush, over the bandage. This is allowed 
to dry before a second and a third layer of the bandage are 
applied. After each bandage a coating of dextrin is applied. 
After the final bandage several coatings of dextrin are applied, 
until a shiny, smooth surface results. This bandage maybe cut, 
and, by the addition of strips of leather along the cut edge upon 
which are hooks, may be laced and unlaced as necessary (see 

F»gs. 596, 597). 



CHAPTER XIX 
THE AMBULATORY TREATMENT OF FRACTURES 

By the ambulatory treatment of fractures of the lower ex- 
tremity is understood a method of treatment that permits the 
immediate and continued use of the injured limb as a means of 
locomotion. 

Medical literature contains many references to this method. It 
has been in use for some ten years. It has not met with general 
acceptance 6ven among hospital surgeons. It is a radical method 
and open to criticism. It contains, however, several important 
suggestions. It will prove instructive to follow the adoption of 
this method by its advocates, and to discover, if possible, what 
there is in it of permanent value. 

Orthopedic surgeons as early as 1878 conceived the idea of 
allowing a patient with a fracture of the thigh or of the leg to 
walk about by means of apparatus. Thomas, of Liverpool, and 
Dowbrowski used the Thomas knee-splint in the treatment of 
fractures certainly as early as the year 1881 or 1882. Krause, a 
German surgeon, published, in 1891, the first account of the 
treatment of fractures of the bones of the leg in walking patients. 
Krause demonstrated that plaster-of- Paris could be used as a 
splint in fractures of the leg and in transverse fractures of the 
thigh. Korsch, in 1894, presented a paper to the German Sur- 
gical Congress demonstrating that compound fractures of the leg 
and fractures of the thigh may be treated with plaster-of- Paris 
s[)lints and early use. Korsch makes permanent extension in a 
thigh fracture, while traction is maintained by an assistant, 
by applyin<^ the plaster directly to the skin, snugly to the 
niallcoli, tlic dorsum of the foot, and the heel. A padded ring 
is incori)(>ratcd into the upper limit of the plaster splint around 
tlic thi^^h, which presses against the tuberosity of the ischium, and 

thus accomphshcs counterextension. Korsch's cases were treated 

440 



HISTORICAL CONSIDERATIONS 44 1 

in Bardeleben's clinic. Bruns, of Tubingen, in 1893, described 
a splint for use in these cases of fracture of the leg and thigh. 
Dollinger, of Budapest, in 1893, described a splint for the 
ambulatory treatment of fractures of both bones of the leg, and 
reported three cases. Dollinger's method of applying the 
plaster-of- Paris splint is the one generally used whenever the 
ambulatory treatment is employed. The method is described 
later. 

Warbasse, at the Methodist Episcopal Hospital of Brooklyn, 
N. Y., in 1893, was the first in this country to adopt systemat- 
ically Dollinger's method. Warbasse reports six cases — all in 
young adults. Bardeleben reported, in 1894, one hundred and 
sixteen cases treated with walking splints. There were eighty- 
nine fractures of the leg, complicated and uncomplicated ; five 
fractures of the patella ; twenty-two fractures of the thigh, five 
of which were compound ; three cases of osteotomy for genu 
valgum. Bardeleben lays down the following law : *• It is of the 
greatest advantage to the patient that such a dressing can be 
applied to the broken leg that he can bear the weight of the body 
upon it and walk about ; but such a method of treatment should 
be applied only under medical supervision, and with the most 
careful consideration of complications that might arise." Korsch 
presented to the German Surgical Congress, in 1894, seven 
cases — three of the thigh and four of the leg. Albers, in 1894, 
reported seventy-eight cases (fifty-six of the leg, five of the 
patella, sixteen of the thigh, and one of the leg and thigh) 
treated by the ambulatory method. He seems to be a little 
more cautious than other German surgeons in this matter. He 
says that when great pain is present, it is best to employ injec- 
tions of morphin. 

Elevation of the limb will often reduce the swelling ; when 
this does not suffice, the bandage must be removed. Severe local 
pain from pressure indicates the necessity for cutting a fenestrum. 
The first attempt at walking should be made on the day follow- 
ing the application of the cast. A crutch and cane are used at 
first ; later, two canes are employed ; and, finally, some patients 
walk without any support at all. Krause, in 1894, reported 
seventy-two cases treated. He is of the opinion that the ambu- 



44-2 THE AMBULATORY TREATMENT OF FRACTURES 

latory treatment in plaster splints must be limited principally to 
fractures and osteotomies in the region of the malleoli, the leg, 
and the lower end of the thigh. He does not employ the method 
in the handling of oblique fractures of the femur and fractures of 
the neck of the femur. Bardeleben writes again in 1895, report- 
ing up to that date one hundred and eighty-one cases treated by 
the ambulatory treatment. This last report, of course, included 
the one hundred and sixteen cases of the previous record. Dr. 
Edwin Martin, before the Surgical Section of the College of 
Physicians of Philadelphia on December, 1895, reported twenty 
cases of fracture of the leg treated by this method. Dr. E. S. 
Pilcher, of Brooklyn, N. Y., in whose wards Warbasse worked, 
reported to the American Surgical Association the twenty or 
more cases treated by him in which the results were satisfactory. 
N. P. Dandridge, of Cincinnati, Ohio, has used the method in 
eight cases. In most of the cases pain was complained of when 
weight was borne on the foot. In a feeble woman it was neces- 
sary to remove the cast in the third week. In the case of a man, 
— a compound fracture of the leg, — after walking two weeks he 
had so much pain that the plaster was removed. Redness and 
swellinj^ were great at the seat of fracture, and there was much 
swelling over tlie internal malleolus. Woodbury introduced the 
method at Roosevelt Hospital, New York city, and Fiske has re- 
ported cases treated at tliat clinic. Roberts, of Philadelphia, and 
Woolsey, of New York, have used the method in selected 
cases with satisfaction. A. T. Cabot, of Boston, has used, in 
several fractures of the femur, Taylor's long hip-splint. E. H. 
Bradford, of Boston, has treated cases of fracture at the Chil- 
dren's Hospital by a modified Thomas knee splint, with and 
without plaster-of- Paris splinting (Eig. 608). 

Those advocating the ambulatory treatment suggest its appli- 
cation to fractures of the leg below the knee, both simple and 
compound, and in fractures of the lower end of the femur. The 
apparatus is not to be applied for three or four days if there is 
much primary swelling. 

The method of application of the plaster splint in the 
ambulatory treatment of fractures of the tibia and fibula alone 
is as follows (this is practically the method of Dollingcr) : First 



THE METHOD APPLIED TO THE TIBIA AND FIBULA 



443 



comes the cleansing of the skin of the leg with soap and water 
and then the reduction of the fracture. Then, with the foot 
fixed at a right angle to the leg, a flannel bandage is smoothly 
and evenly applied from the toes to just above the knee. This 
bandage is made to include beneath the sole of the foot a pad- 
ding of ten or fifteen layers of cotton wadding, making a pad 




Fig. 6B9.-Thon 



about three-fourths of an inch thick, after it is compressed by 
the moderate pressure of the flannel bandage. Over this is now 
applied the plaster bandage from the base of the toes to just 
above the knee, especial care being taken that the application is 
made smoothly and somewhat more firmly than is the custom in 
the ordinary plaster cast. The layers of the bandage should be 
well rubbed as they are applied, with a view to obtaining the 



444 THE AMBULATORY TREATMENT OF FRACTURES 

greatest amount of firmness with the smallest amount of material. 
The sole is strengthened by incorporating with the circular 
turns an extra thickness composed of ten or twelve layers of 
bandage well rubbed together, and extending longitudinally along 
the sole. The bandage is applied especially firmly about the 
enlarged upper end of the tibia, and here it is made somewhat 
thicker. As it dries it may be pressed in so as to conform more 
closely to the leg just below the heads of the tibia and fibula. 
The assistant who stands at the foot of the table and supports 
the leg makes such traction or pressure as is required to keep 
the fragments in proper position while the plaster is being 
applied. The operation requires about twenty minutes, and by 
the time the last bandage is applied the cast should be fairly 
hard. 

It is seen that when this cast has become hardened the leg is 
suspended. When the patient steps upon the sole of the plas- 
ter cast, the thickness of the cotton beneath the foot separates 
the sole of the foot so far from the sole of the cast that the foot 
hangs suspended in its plaster shoe. Thus the weight of the 
body, which would come upon the foot, is borne by the diverging 
surface of the leg above the ankle. The chief of these is the 
strong head of the tibia. A lesser role is played by the head of 
the fibula and the tapering calf in muscular subjects. 

In thigh fractures the use of the long Taylor hip-splint, 
together with a high sole upon the well foot and crutches, is 
generally accepted as the best method of ambulatory treat- 
ment. 

The advantages claimed for the ambulatory method are : 

Time is saved to the business man by this method — he having 
to give up but about seven days to a fracture of the leg. The 
time spent by the patient in the hospital is less than by other 
methods. The general health is conserved ; whereas by the old 
mctliocl the appetite is variable, sleep is troubled, the bowels are 
constipated, and general discomfort prevails. There is greater 
general comfort by this method than by any other. In drunk- 
ards and those with a tendency to delirium tremens this liability 
is c^reatly diminished. In old people the danger of a hypo- 
static {)neumonia is lessened. The primar\^ swelling associated 



THE ADVANTAGES CLAIMED FOR THE METHOD 445 

with a fracture is often avoided, and always less than by the 
older methods. The secondary edema and muscular weak- 
ness are less. The functional usefulness of the whole leg is 
greater. There is less atrophy of the muscles of the thigh and 
leg. The amount of the callus is diminished. There is less 
stiffness of neighboring joints. Union in a fracture occurs at an 
earlier date. 

Before this method can be adopted generally and in hospital 
treatment it must be demonstrated that it is safe, and that it offers 
chances of better functional results than are obtained under 
present methods, and that the minor advantages claimed for it by 
ardent German advocates are real and not imaginary. The first 
great advantage of the method is stated to be that the stay in the 
hospital and the time away from one's occupation are much 
lessened. Regarding this point the Massachusetts General 
Hospital Surgical Records were consulted for these three periods : 
before the use of plaster-of- Paris — that is, previous to 1865 ; just 
at the beginning of the use of plaster-of- Paris as a splint for frac- 
ture, and in 1895. 1896, and 1897. Thirty- five unselected cases 
of fracture of the tibia and fibula were tabulated from each period. 
The duration of the average time spent in the hospital in the first 
period — i.e., previous to 1865 — was forty-six days; in the 
second period — /. e,, about 1866— it was forty-five days ; at the 
present time it is sixteen days. In the second period plasters 
were applied to fractured legs on an average at about the twenty- 
eighth day ; at the present time, on the fourteenth day. In other 
words, there has been since the introduction of the plaster splint 
a gradually shorter detention in the hospital, as surgeons have 
come to recognize the safety of an earlier application of a fixed 
dressing. On an average, patients with fracture of the leg are 
detained in the hospital to-day but sixteen days. The very 
great saving to the hospital in time by the ambulatory treatment 
does not, therefore, appear. It is impossible to consider the 
statements made with regard to rapidity of healing, sign of callus, 
absence of muscular atrophy, and absence of rigidity of joints, 
because there are no facts available for the purpose. The advan- 
tages stated are based, most of them, upon the jx^rsonal impres- 



446 THE AMBULATORY TREATMENT OF FRACTURES 

sions of the surgeon in charge ; impressions compared with 
scientific observations are untrustworthy. 

Krause presents a table from Paul Bruns containing the aver- 
age periods of healing in a series of fractures, and compares these 
periods with his own fracture cases treated by the ambulatory 
method. This is the only attempted scientific statement of obser- 
vation on this important point. Krause concludes from a study 
of these tables that, ** In the treatment of fractures of the middle 
and upper thirds of the leg, the ambulatory method shows a great 
advantage in the period of consolidation as well as in the time 
when the patient can return to work. It seems that the higher 
up the fracture is in the leg, the sooner a cure is efifected by the 
ambulatory method of treatment." 

Conclusions. — A review of the literature does not disclose 
any other advantage in the results of the ambulatory treatment 
over the present treatment of fractures of the leg than that stated 
by Krause. The present commonly accepted method of treating 
fractures of the femur by long rest in the horizontal position, 
with extension by weight and pulley, is not satisfactory. The 
protracted stay in bed is undesirable. The use of the Taylor 
hip-splint in the treatment of this fracture, assisted by coaptation 
splints or a splint of pi aster- of- Paris, is of distinct value. This, 
however, is a somewhat well-known method of ambulatory 
treatment. 

Theoretically and practically, the ambulatory treatment does 
not perfectly immobilize ; therefore, it can not preeminently suc- 
ceed as a means of treatment. The method in general .seems to 
be unsurgical. P^mbolism, both of fat and of blood, and the 
likelihood of pressure -so res in the use of the plaster splint are 
dangers to be considered. It is wise to allow the injured limb 
to rest while the reparative process is beginning. Muscular 
relaxation is desirable in the treatment of fractures. The very 
admission by the advocates of the ambulatory treatment that 
muscular contractions take place is reason enough for supposing 
that complete immobilization is not obtained by this method. 
However, in certain carcfulK' selected cases of fracture below 
tile knee, particularly of the fibula, if under the care of a com- 



THE ADVANTAGES CLAIMED FOR THE METHOD 447 

petent and skilful surgeon, it is possible to conceive of the ambu- 
latory method being used without doing harm. 

A consideration of the ambulatory treatment of fractures 
should lead to a more careful and early use of the plaster-of- 
Paris splint in fractures of the leg, and to a proper application of 
the long hip-splint or its equivalent in fractures of the thigh, and 
to the early use of crutches and the high sole on the well foot in 
both of these lesions. 

Materials for the Ordinary Care of Closed Fractures 

The materials with which a physician should be provided in 
order to properly care for the fractures ordinarily met with are 
comparatively few. 

There is scarcely a fracture which can not be treated satisfac- 
torily by the proper use of plaster-of-Paris. 

Plaster-of- Paris roller bandages. 

Washed crinoline. 

Plaster-of-Paris. 

A jack-knife, for splitting plaster dressings. 

A pair of heavy scissors. 

Thin splint wood, ^ of an inch in thickness. 

Iron wire, J^ of an inch in diameter. 

Posterior wire splint, for adult leg. 

Anterior wire splint, for adult leg. 

Surgeon's adhesive plaster. 

Cotton and cheese-cloth roller bandages. 

Sheet wadding for padding, splints. . 



i 



:¥ 



1- 



BIBLIOGRAPHY 

The important contributions to literature which have been consulted are recorded 
below. Dr. Stimson's book upon " Fractures" will always stand as a classical work 
in its especial field. Dr. Poland's work upon *'The Epiphyses" is also a very 
valuable contribution to fracture literature. The text has been kept free of all 
references in order that greater clearness might result. 



Hamilton, Fractures and Dislocations. 

Stimson, A Practical Treatise on Fractures and Dislocations, Lea Bros., 1899. 

Helferich, Atlas of Traumatic Fractures and Luxations, with a Brief Treatise, Wm. 

Wood & Co., 1896. 
Roberts, P. Blakiston, Son & Co., Philadelphia, 1897. 
Wharton and Curtis, The Practice of Surgery. 

The International Encyclopedia of Surgery ; supplementary volume vii, 1895. 
Dennis, F. S., System of Surgery, 1895. 
Cheever, Lectures on Surgery, Damrell and Upham, Boston, 1894. 



FRACTURE OF THE SKULL 
Huguenin, Cyclopaedia practische Medicin, Ziemssen, Band xii, 1897. 
Mills, The Nervous System and Its Diseases, 1898. 
Bradford and Smith, Transactions of the American Surgical Association, volume 

LX, page 433- 
Bullard, Medical and Surgical Reports of the Boston City Hospital, 1897. 
Dana, Text- book of Nervous Diseases. 

Courtney, Boston Medical and Surgical Journal, April 6, 1899, page 345. 
Hill and Bayliss, Journal of Physiology, London, 1895, xviii, page 324. 
Walton, American Journal of Medical Sciences, September, 1898. 
Putnam, Walton, Scudder, Lund, American Journal of Medical Sciences, April, 

1895. 

FRACTURE OF THE NASAL BONES 

Bosworth, Diseases of Nose and Throat, third edition, pages 157-161. 

Zuckerkandl, Anat. norm, et Patholog. des Fosses Nasales, volume I, page 429. 

Evans, Deflections of the Nasal Septum, Louisville Journal of Surgery and Medi- 
cine, volume V, June, 1898, pages I-4. 

Casselberry, Deformities of the Septum Narium, Transactions of the American 
Medical Association, volume xxii, No. 9, pages 469-471. 

Cobb, Fracture of the Nasal Bones, Journal of the American Medical Association, 
volume xxx, 1898, page 588. 

Frcytag, Monatsschrift f Ur Ohrenheilkunde, 1896, Band xxx, Seiten 217-224. 

Zuckerkandl, Anatomic der Nasenh5hle, Band ii. 
29 449 



450 BIBLIOGRAPHY 

Watsin, Lancet, 1896, volume i, page 972. 

Roc, The American Medical Quarterly, June, 1899. 

FRACTURE OF THE SPINE 

Thorbum, A Contribution to the Surgery of the Spinal G>rd. 

Walton, Boston Medical and Surgical Journal, December 7, 1893. 

Thomas, Boston Medical and Surgical Journal, September 7, 1899, page 233. 

Dennis, Annals of Surgery, March, 1895. 

Burrell, Transactions of the Massachusetts Medical Society, 1887. 

Taylor, Journal of the Boston Society of the Medical Sciences, December, 1898. 

Wagner and Stolper, Die Verletzungen des Wirbels&ule und des Riickenmarks, 

1898, Seile 415. 
Kocher, Mittheilungen Grenzgebieten der Medicin und Chirurgie, 1896. 
White, Transactions American Surgical Association, vol. IX. 
Cheever, Boston Medical and Surgical Journal, September 28, 1893. 
Pilcher, Annals of Surgery, volume xi, pages i87-2cx>. 
Prewitt, Transactions American Surgical Association, volume xvi, page 255. 

FRACTURE OF THE SCAPULA 

Blake, Boston City Hospital Reports, 1899, page 36S. 

FRACTURE OF THE HUMERUS 

Bruns, Deutsche Chirurgie, Theil 28, 2. HSlfte. 

Murray, New York Medical Journal, June 25, 1892. 

Monks, Boston City Hospital Medical and Surgical Reports, 1895 ; also Boston 

Medical and Surgical Journal, March 21, 1895, January 9, 1896, and December 

4, 1895. 
Lund, Boston City Hospital Reports for 1897, page 389. 

Allis, Annals of the Anatomical and Surgical Society, Brooklyn, 1880, ii, 289. 
Smith, Boston Medical and Surgical Journal, July, 1895. 
Stimson, Roberts, Allis, Transactions of the American Surgical Association, 1881 

to 1898. 

FRACTURE OF THE FOREARM 

Pilcher, Paper read to Association of Military Surgeons of the United States, Berlin 
Printing Co., Columbus, Ohio. Medical Record, 1878, ii, 74. Annals of An- 
atomical and Surgical Association, Brooklyn, 1887, ill, page ^^. 

Moore, Transactions of the Medical Society, State of New York, 1880. 

Bolles, Boston City Hospital Reports, third series, 1882, page 340. 

Conner, Journal of the American Medical Association, 1894, page 54. 

Roberts, Medical News, 1890, LVll, 615. Annals of Surgery, 1892, xvi. 

Mouchet, A., Revue de Chirurgie, May, I900. 

FRACTURE OF THE THIGH 

Cabot, Boston Medical and Surgical Journal, January 3, 1884, page 6. 
Allis, Transactions of the American Surgical Association, volume IX, 1891, page 
329. Medical News, November 21, 189I. 



BIBLIOGRAPHY 45 1 

Hutchinson, Lancet, 1898, ii, 1630. 

Packard, International Kncyclo})8edia of Surgery. 

Whitman, Annals of Surgery, June, 1897, page I. 

Senn, Journal of the American Medical Association, August 3, 1889. 

Ridlon, Transactions of the American Orthopedic Association, 1897, page 186. 

Lane, Medicocbirurgical Transactions, London, 1888. 

Scudder, lk>ston Medical and Surgical Journal, March 22, 29, 1900. 

SEPARATION OF THE LOWER EPIPHYSIS OF THE FEMUR 

Annals of Surgery, Philadelphia, 1898, xxviii, 664. 

Annals of Gynecology, November, 1890. 

British Medical Journal, December, 1894, page 671. 

New York Medical Record, October 5, 1895. 

Annals of Surgery, March, 1896. 

Archives G^n^rales, March and April, 1884, volume xiii, page 272. 

Transactions of the American Sui^ical Association, 1895. 

Liverpool Medicocbirurgical Journal, January, 1885, page 41. 

Liverpool Medicocbirurgical Journal, July, 1883. 

Stimson, PVactures and Dislocations, 1899. 

Hutchinson, Lancet, May 13, 1899. 

McBurney, Annals of Surgery, March, 1896, xxii, 506. 

Harte, Transactions of the American Surgical Association, 1895. 

Deleus, Archives G^ndrale de Medicine, 1884, volume xiii, page 272. 

Poland, Traumatic Separation of the Epiphyses, 1898. 

Smith, Transactions of- the American Surgical Association, volume viii. 

FRACTURE OF THE PATELLA 

Powers, Annals of Surgery, July, 1898. 

Bull, New York Medical Record, xxxvii, 1890. 

McBumey, Annals of Surgery, 1895, ^^^* 3^^' 

Pilcher, Annals of Surgery, 1890, xii. 

Stimson, Annals of Surgery, 1895, xxi, 603 ; 1896, xxiv, 45. 

Cabot, Boston Medical and Surgical Journal, cxxv. 

Dennis, System of Surgery. 

Lund, Boston Medical and Surgical Journal, 1896, cxxxv ^^S. 

Fowler, Annals of Surgery, January, 1891. 

Macewen, Annals of Surgery, 1887, volume v, page 177. 

Phelps, New York Medical Journal, June, 1890. 

White, New York Medical Record, October 27, 1888. 

Beach, New York Medical Record, March 15, 1890. 

FRACTURE OF THE LEG 
Cabot, The Boston Medical and Surgical Journal, January 3, 1S94, page 6. 
Lovett, Boston City Hospital Medical Reports, 1899, page 222. 
Allis, Annals of Surgery, 1897. 
Tiffany, Annals of Surgery, 1896, xxiii, 449. 
Lane, Transactions of the Clinical Society, London, xxvii, 167, 



452 BIBLIOGRAPHY 

Stimson, New York Medical Journal, June 25,1892. 

Smith, N. R., Treatment of Fractures of the Lower Extremity, BaUimore, Kelly 
and Piet, 1 867. 

THE AMBULATORY TREATMENT OF FRACTURES 
Krause, Deutsche medicinische Wochcnschrift, 1891, No. 13. 
Korsch, Berliner klinische Wochenschrift, No. 2. 
Bnins, Beitr&ge zur klinische Chirurgie, Band X, Heft ii, 18. 
Dollinger, Centralblatt fiir Chirurgie, 1893, No. 46. 
Warbasse, Transactions of the Brooklyn Surgical Society, October, 1894. 
Bardeleben, Verhandlungen der deutsche Oesellschaft fiir Chirurgie, XXIII. Kon- 

gress, 1894. 
Albers, Verhandlungen der deutsche Gesellschaft fiir Chirurgie, XXIII. Kongress, 

1894. 
Krause, Verhandlungen der deutsche Gesellschaft fiir Chirurgie, XXIII. Kongress, 

1894. 
Pilcher, Transactions of the American Surgical Association, volume xiv, 1896. 
Woodbury, New York Medical Record, 1897. 

Roberts, Transactions of the American Surgical Association, volume xiv, 1896. 
Woolscy, New York Medical Record, 1897. 
Cabot, New York Medical Record, 1897. 
Bradford, New York Medical Record, 1897. 

THE EPIPHYSES 
Quain, Dwight, Gray, Morris. 

Poland, John, f.r.c.s., Traumatic Separations of the Epiphyses, 1898. 
BrQnne, Das Verhtltniss die Gelenkkapselen zu die Epiphyse die Extremitilten- 
Knochen. 

MASSAGE 
Bennett, W. H., London Lancet, June 2, 1900 ; London Lancet, Feb. 5, 1898. 



INDEX 



Ambulatory treatment of 
fractures, 440 

Conclusions as to ambulatory treat- 
ment, 446 
Plaster splint, 442 



Biblios^raphy, 449 
Bones of the foot, 396 

Astragalus, 396 

Hot-air baking, 400 

Massage, 400 

Metatarsal bones, 401 

Open fracture of astragalus and os 

calcis, 401 
Os calcis, 397 
Phalanges, 402 
Treatment, 399 



Carpus, metacarpus, pha< 
tansies, 242 
Carpus, 242 

Treatment, 243 

Metacarpal bones, 245 

Method of reduction, 245 
Symptoms, 245 
Treatment, 246 

By pads, 248 

Massage. 251 

Pads and extension, 249 

Use of roller bandage, 249 

Clavicle, 106 

Anatomy, 106 
In childlioofl, 109 
Operative treatment, 1 16 
Prognosis, 116 
Symptoms, 107 
Treatment, 109 

In adults, 109 

In children, 113 

Modified Sayre dressing, 112 

Recumbent {>osture, 109 

Clinical cases, 38 

Injury to the head, 38 

Colles* fracture, 219 

Anatomy, 218 



Associated lesions, 231 

Care of splint, 237 

Contusion of bones near the wrist, 228 

Differential diagnosis, 227 

Dislocation of the wrist backward, 228 

Examination, 220 

Fracture of forearm near wrist, 229 

Massage, 238 

Method of reduction, 232 

Prognosis, 240 

Result, 240 

Retentive apparatus, 235 

Reversed Colles' fracture, 240 

Separation of lower radial epiphysis, 

229 
Sprain of the wrist, 227 
Symptoms, 222 
Treatment, 232 



Elbow (lower end of the hu- 
merus), 155 

Aftercare of elbow injuries, 183 
Differential diagnosis of elbow-region 

lesions, 164 
Dislocation of the radius and ulna 

backward, 164 
Fracture of the external condyle, 168 
Fracture of the head and neck of 

the radius, 166 
Fracture of the internal condyle, 167 
Fracture of the internal epicondyle, 

167 
Fracture of the olecranon process ot 

ulna, 166 
Separation of the lower epiphysis of 

the humerus, 175 
Subluxation of the head of the ra- 
dius, 164 
T- fracture into ell)ow-joint, 1 75 
Transverse fracture of shaft of the 

humerus, 168 
Methoil of examination, 157 
Carrying angle, 159 
Head of the radius, 159 
Measurements, 160 
Movements at elbow -joint, 1 59 
Three bony |>oints, 157 
Possible lesions of elbow region, 163 



453 



454 



INDEX 



Prognosis, 185 

Summary of examination of elbow, 161 

Treatment, 176 

Acutely flexed position, 177 

Epiphyses, 403 

Acromion process of scapula, 408 
Dates of ossification, 404 
Lower epiphysis of the femur, 405 
Lower epiphysis of the humerus, 407 
Lower epiphysis of the radius, 406 
I^wer epiphysis of the tibia, 408 
Order of frequency of separation, 404 
Upper epiphysis of the humerus, 405 
Upper epiphysis of the tibia, 408 



Fat embolism, 318 
Femur, 256 

Ambulatory treatment, fracture of 

femur, 299 
Anatomy, 256 
Expectant treatment, 296 
Massage, 298 
Prc^^osis, 300 
Result to be satisfactory, 300 
Results, 301 
in cliiidliood, 305 
Treatment, 305 

Bradford frame, 308 

Bradford frame, construction, 309 

Buck's extension, 305 

Cabot posterior wire splint, 305 

Plaster of- Paris. 305 

Lower epipliysis of, 309 

Separation, 309 
Anatomy, 309 
Diagnosis, 313 
Prognosis, 314 
Treatment, 314 

After-treatment, 316 
Massage, 317 
Operative reduction, 315 
Reduction by manipulation, 315 
Necic of, in adults, 256 
Bryant's triangle, 261 
Examination, 259 
Measurement, 260 
Prognosis. 264 
Results, 264 
Symptoms, 257 
Treatment, 265 

After-care of traction method, 268 
Construction of Thomas' hip- 
splint, 269 
Fixation method, 268 
General considerations, 265 
Lateral pressure, 273 
Simple traction method, 267 
The bed, 267 
Thomas' hip-splint, 269 



Thomas' hip-splint, application 

of, 271 
Thomas* hip-splint, summary of 

construction, 270 

NecIc of, in cliildren, 274 

Treatment, 276 
Sliaft of, in adults, 278 

Backward bending of injured thigh, 

294 
Buck's extension, 285 
Measurements, 278 
Method of examination, 284 
Objects of treatment, 282 
Outward bowing of injured thigh, 

293 
Rotation outward of injured thigh, 

293 
Shortening of injured thigh, 293 

Symptoms, 278 

Transportation of patient, 279 

Treatment, 279 
Subtroclianteric fracture, 295 

Expectant treatment, 295 

Operative treatment, 296 
Supracondyloid fracture, 296 

After-treatment, 297 

Tenotomy, 296 

Forearm, 187 

Coronoid process of the ulna, 193 

Greenstick fracture, 187 

Head and neck of radius, 189 

Radius and ulnA, 187 

Separation of the lower epiphysis of 

radius, 19 1 
Shaft of the radius, 190 
Shaft of the ulna, 193 
Symptoms. 187 

Treatment, 194 

After-care of the plaster splint, 198 
After-care of wooden splint, 203 
Application of the woioden splint, 
201 

Fracture of botli radius and 

ulna, 194 
Fracture of necIc of radius, 

and coronoid of ulna, 204 
Fracture of sliaft of radius, 204 
Fracture of shaft of ulna, 204 
Qreensticic fracture of bones 

of forearm, 209 
Length of time splints remain on , 205 
Massage, 205 
Palmar and dorsal wooden splints, 

200 
Precaution in using plaster-of- Paris 

splint, 197 
Prognosis, 206 
Result of treatment, 206 

Separation of lower radial 
epipliysis, 204 



Hemorrhagic internal pachy i 

meningitis, 30 ! 

Humerus, tzi { 

Anaiomy, iii ' 

Lower end ol humerus. Se« ' 

KItisw. I 

Malignant disease at seat of j 

fracture, 155 
JHusculospiral nerve, 153 

Symplonis of involvement, 154 

Treaimeni of Ihe iMion, 154 

Shaft o( the humerus, 144 
New-born fraclures, 153 
Prognosis, 153 

Spiral fracture of humerus, t44 
Symptoms, 144 
Treument, 146 

Little or no displacement, 146 



Upper end ol the r 

After care. 140 
Aflet'lreniineTil of operated cases of 
dislaculioti uF upper ftagmeni, 143 
Diagnosis. Ij6 

Dislocation af humeral head, 137 
Dislocation of upper frai^liif Dt com- 
plicating fracture, I42 
Examination of shoulder, izz 
Fracture of anatomical neck, 118 
Fracture of surgical neck, 136 
Oblique fracture of surgical neck, 

14a 
Prognosis, 140 

Result, 140 I 

Separation of the upper epiphysis. 1 



Fractures of analomical and sur- 
gical necks, 137 

Separation of the upper humeral 
epiphysis. 137 



Inferior maxilla, 58 

Examination, 59 
Symptoms, 59 
I. 61 



Body and ramus. 61 I 

Body and ramus upon the same or 1 

opposite sides, 70 | 
Coronoid and articular processes, 71 

Making; of dental splint, 66 ! 

Ramus of maxilla, 68 I 

Leg. 341 I 

Examination of fractured leg. 346 | 

General observations, 345 I 

Symptoms, 34S ! 



Care of the heel, 361 

Care after permanent dressing is ap- 
plied, 372 

Fractures difficult to hold re- 
duced, 365 

Plasler-of-hri- splint, 368 
Operative melhods, 368 
Fractures with considerable 

immediate swelling, 354 
Fractureswith Utile displace- 
ment or swelling, 351 

Massa4;p, 574 
'l]ien fr^ui 



J'e. 



36J 



.370 



Permanent dressing, 359 

Pillow and side splints, 357 

PI aster-of- Paris, 359 

Posterior wire and aide splints, 359 

Posterior wire splint, method uf 

making. 360 
Prt^nosis. 376 

Refraciure of bones of ihe leg, 378 
Results after fracture of the 1^, 377 
Tem|«rary dressing, 357 

Thrombosis and embolism, 37S 

Malar, 52 

Examination, 52 
Palpation of, 52 
Symptoms. 53 
Treatment, 54 

Nono|ierativc, 54 

Operative, 55 

Mai gnant edema, 31 7 
Materials needed for care of 

closed fractures, 447 
Medicolegal relations of Rdnt- 

gen ray, 413 



I Nasal bone, 
I Anatomy , 44 



44 



Pr^ 



1,47 



Symptoms, 46 

Adhesive plaster. SO 
Asch's lube, 49 
Cleansing naaal cavity, 
Cobb's splint. 50 
Coolidge's splint, 50 
Hematoma of sefitum, 
Roe's elevator, 49 
Tin splint. 50 



456 

Nonunion of fractures. 



Olecranon, no 
Ahercare. 216 

Summary or Ircalmenl, 1 

Trexmenl, nonoperalive 



Patella, 319 



After-trewment. 33' 
Causn of fraeiure. 313 
Mainieniinceafreduciion, 329 
Massage, 326 
0]>cn rrBc(ucc,333 

Operative treatment In recent 
closed fractures, 337 

LimilHllons of. JJ9 
Method of, 340 



of fun 



1, 340 



PlaslW-ofPnri'* splint, 330 

Prognoiiis, 334 

Reduction of ihe fraements, 317 

Removable splLiK, 330 

Restoration of the function of the joint, 

332 
Results, 336 
Symptoms, 313 
Trea(meni, 314 



Pott's fracture, 379 



Aoali 



'.379 



Cate after peimanent dressing, 392 

Dupuylren s|)liut, 3S6 

Massage, 39.1 

Open Hott's fracture, 394 

(Jptraiivc ireaiment of old Poll's frac- 
lure, 394 

Flasler-of Paris splinls, 390 

Prof;!io5i,, 394 

Poslerior wire splint with curved foot- 
piece, 389 

Results. 394 

Stimson's splint, 390 

Symptoms, 381 

Trealmenl, 382 



Symptoms, 91 
Treatment, expectant, c 
Rontgen ray, 409 



Scapula, 11S 

Itodyof, IlS 



Septicemia, 517 
Skull. 17 



Phalanges, 251 

n|ieii fracturi.- of phalanges, 254 



Plaster-of- Paris, 425 



cr-of-Pari! 
1.438 



tleneralob! 

Inlerval of consciousness. 

Laceration of tlie brain, l< 

I,alerte-uUs38 

()|wrative treatment, 35 

Pistol shot wounds. 37 

Siiharaclinoid >er<«is exu<l 
Sviiiploms of fracluie of I 



INDEX 



457 



sternum, 96 

Treatment, 97 
Operative, 98 

Position for reducing ordinary dis- 
placement, 97 

Superior maxilla, 55 

After-care, 57 
Diagnosis, 55 
Treatment, 56 

Closed fracture, 56 

Open fracture, 56 



Tetanus, 219 ! 

Traumatic gangrene, 317 



Unconsciousness, causes of, 29 



Vertebrae, 72 

Anatomy, 72 



Examination of injury to spine, 75 

General symptoms common to all frac- 
tures, 76 

Gunshot fracture of, 90 
Treatment, 90 

Lesions tabulated by regions, 75 

Prognosis, 81 

Symptoms of injury to cervicodorsal 
vertebra?, 79 

Symptoms of injury to dorsal verte- 
brae, 78 

Symptoms of injury to last dorsal 
vertebrae, 77 

Symptoms of injury to midcervical 
vertebrae, 80 

Symptoms of injury to the first two 
cervical vertebra*, 80 

Treatment, 81 
Cystitis, 89 

Operative interference, 84 
Plastcr-of- Paris jacket, 87 
Signs of partial lesion, 82 
Signs of transverse lesion, 81 
Summary, 89 



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